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AdultDevelopmentandAgingbyJohnC.CavanaughFreddaBlanchard-Fieldsz-lib.org.pdf
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7th Edition
ADult Development and Aging
Australia • Brazil • Mexico • Singapore • United Kingdom • United States
John C. Cavanaugh Consortium of Universities of the Washington Metropolitan Area
Fredda Blanchard-Fields
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Adult Development and Aging, 7th Edition
John C. Cavanaugh and Fredda Blanchard-Fields
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WCN: 02-200-203
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In memory of Fredda Blanchard-Fields, friend and collaborator, who dedicated her life to educating students.
To Chris
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iv BRIEF CONTENTS
BRIEF CONTENTS ChAPTER 1 Studying Adult Development and Aging _____________________________________________________________________________________________________________________________________________________________________1
ChAPTER 2 Neuroscience as a Basis for Adult Development and Aging ____________________________________________________________________________________________________________ 32
ChAPTER 3 Physical Changes _____________________________________________________________________________________________________________________________________________________________________________________________________________________________57
ChAPTER 4 Longevity, Health, and Functioning _____________________________________________________________________________________________________________________________________________________________________________ 92
ChAPTER 5 Where People Live: Person–Environment Interactions _________________________________________________________________________________________________________________________ 127
ChAPTER 6 Attention and Memory ____________________________________________________________________________________________________________________________________________________________________________________________________________ 157
ChAPTER 7 Intelligence, Reasoning, Creativity, and Wisdom ________________________________________________________________________________________________________________________________________ 185
ChAPTER 8 Social Cognition _____________________________________________________________________________________________________________________________________________________________________________________________________________________________ 216
ChAPTER 9 Personality ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________245
ChAPTER 10 Clinical Assessment, Mental Health, and Mental Disorders ________________________________________________________________________________________________________ 274
ChAPTER 11 Relationships ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 310
ChAPTER 12 Work, Leisure, and Retirement____________________________________________________________________________________________________________________________________________________________________________________ 342
ChAPTER 13 Dying and Bereavement _____________________________________________________________________________________________________________________________________________________________________________________________________ 375
ChAPTER 14 Successful Aging _________________________________________________________________________________________________________________________________________________________________________________________________________________________ 405
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CONTENTS v
CONTENTS
Chapter 1 Studying Adult Development and Aging 1 1.1 Perspectives on Adult Development and Aging 3
Discovering Development: Myths and Stereotypes about Aging 4
THE LIFE-SPAN PERSPECTIVE 4 THE DEMOGRAPHICS OF AGING 5
Adult Development in Action 10
1.2 Issues in Studying Adult Development and Aging 10 THE FORCES OF DEVELOPMENT 11 INTERRELATIONS AMONG THE FORCES: DEVELOPMENTAL INFLUENCES 11 CULTURE AND ETHNICITY 12 THE MEANING OF AGE 13 CORE ISSUES IN DEVELOPMENT 14
Current Controversies: Does Personality in Young Adulthood Determine Personality in Old Age? 15
Adult Development in Action 17
1.3 Research Methods 17 MEASUREMENT IN ADULT DEVELOPMENT AND AGING RESEARCH 17 GENERAL DESIGNS FOR RESEARCH 19 DESIGNS FOR STUDYING DEVELOPMENT 20
How Do We Know?: Conflicts between Cross-Sectional and Longitudinal Data 24
INTEGRATING FINDINGS FROM DIFFERENT STUDIES 26 CONDUCTING RESEARCH ETHICALLY 26
Adult Development in Action 27
Social Policy Implications 27
SUMMARY 28 REVIEW QUESTIONS 30 INTEGRATING CONCEPTS IN DEVELOPMENT 30 KEY TERMS 30 RESOURCES 31
Chapter 2 Neuroscience as a Basis for Adult Development and Aging 32
2.1 The Neuroscience Approach 34 NEUROIMAGING TECHNIQUES 34 NEUROSCIENCE PERSPECTIVES 35
Discovering Development: What Do People Believe about Brain Fitness? 36
Adult Development in Action 36
2.2 Neuroscience and Adult Development and Aging 37
HOW IS THE BRAIN ORGANIZED? 37 WHAT AGE-RELATED CHANGES OCCUR IN NEURONS? 38 WHAT AGE-RELATED CHANGES OCCUR IN NEUROTRANSMITTERS? 39 WHAT AGE-RELATED CHANGES OCCUR IN BRAIN STRUCTURES? 39 WHAT DO STRUCTURAL BRAIN CHANGES MEAN? 40
How Do We Know?: The Aging Emotional Brain 41
Adult Development in Action 45
2.3 Making Sense of Neuroscience Research: Explaining Changes in Brain-Behavior Relations 45
THE PARIETO-FRONTAL INTEGRATION THEORY 46 CAN OLDER ADULTS COMPENSATE FOR CHANGES IN THE BRAIN? 46 THEORIES OF BRAIN-BEHAVIOR CHANGES ACROSS ADULTHOOD 47
Adult Development in Action 50
2.4 Neural Plasticity and the Aging Brain 50
Current Controversies: Are Neural Stem Cells the Solution to Brain Aging? 51
EXERCISE AND BRAIN AGING 51 NUTRITION AND BRAIN AGING 52
Adult Development in Action 52
Social Policy Implications 52
SUMMARY 53 REVIEW QUESTIONS 54 INTEGRATING CONCEPTS IN DEVELOPMENT 55 KEY TERMS 55 RESOURCES 56
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vi CONTENTS
Chapter 3 Physical Changes 57 3.1 Why Do We Age? Biological Theories
of Aging 58
Discovering Development: Why Do Most People Think We Age? 59
RATE-OF-LIVING THEORIES 59 CELLULAR THEORIES 59 PROGRAMMED-CELL-DEATH THEORIES 60 IMPLICATIONS OF THE DEVELOPMENTAL FORCES 60
Adult Development in Action 61
3.2 Appearance and Mobility 61 CHANGES IN SKIN, HAIR, AND VOICE 62 CHANGES IN BODY BUILD 63 CHANGES IN MOBILITY 63 PSYCHOLOGICAL IMPLICATIONS 67
Adult Development in Action 69
3.3 Sensory Systems 69 VISION 69 HEARING 71 SOMESTHESIA AND BALANCE 73
How Do We Know?: Preventing Falls Through Tai Chi 74
TASTE AND SMELL 75
Adult Development in Action 76
3.4 Vital Functions 76 CARDIOVASCULAR SYSTEM 76 RESPIRATORY SYSTEM 80
Adult Development in Action 81
3.5 The Reproductive System 81 FEMALE REPRODUCTIVE SYSTEM 82
Current Controversies: Menopausal Hormone Therapy 82
MALE REPRODUCTIVE SYSTEM 83 PSYCHOLOGICAL IMPLICATIONS 84
Adult Development in Action 84
3.6 The Autonomic Nervous System 84 AUTONOMIC NERVOUS SYSTEM 85 PSYCHOLOGICAL IMPLICATIONS 86
Begin Adult Development in Action: Adult Development in Actions 86
Social Policy Implications 87
SUMMARY 88 REVIEW QUESTIONS 90 INTEGRATING CONCEPTS IN DEVELOPMENT 90 KEY TERMS 90 RESOURCES 91
Chapter 4 Longevity, Health, and Functioning 92 4.1 How Long Will We Live? 93
Discovering Development: Take the Longevity Test 94
AVERAGE AND MAXIMUM LONGEVITY 94 GENETIC AND ENVIRONMENTAL FACTORS IN AVERAGE LONGEVITY 95 ETHNIC DIFFERENCES IN AVERAGE LONGEVITY 96 GENDER DIFFERENCES IN AVERAGE LONGEVITY 97 INTERNATIONAL DIFFERENCES IN AVERAGE LONGEVITY 98
Adult Development in Action 99
4.2 Health and Illness 99 DEFINING HEALTH AND ILLNESS 99 QUALITY OF LIFE 100 CHANGES IN THE IMMUNE SYSTEM 100 CHRONIC AND ACUTE DISEASES 102 THE ROLE OF STRESS 103
How Do We Know?: Negative Life Events and Mastery 106
Adult Development in Action 107
4.3 Common Chronic Conditions and Their Management 107
GENERAL ISSUES IN CHRONIC CONDITIONS 107 COMMON CHRONIC CONDITIONS 108
Current Controversies: The Prostate Cancer Dilemma 111
MANAGING PAIN 113
Adult Development in Actions 114
4.4 Pharmacology and Medication Adherence 114 PATTERNS OF MEDICATION USE 114 DEVELOPMENTAL CHANGES IN HOW MEDICATIONS WORK 114 MEDICATION SIDE EFFECTS AND INTERACTIONS 115 ADHERENCE TO MEDICATION REGIMENS 116
Adult Development in Action 117
4.5 Functional Health and Disability 117 A MODEL OF DISABILITY IN LATE LIFE 117 DETERMINING FUNCTIONAL HEALTH STATUS 119 WHAT CAUSES FUNCTIONAL LIMITATIONS AND DISABILITY IN OLDER ADULTS? 120
Adult Development in Action 121
Social Policy Implications 122
SUMMARY 122 REVIEW QUESTIONS 124 INTEGRATING CONCEPTS IN DEVELOPMENT 125 KEY TERMS 125 RESOURCES 126
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CONTENTS vii
Chapter 5 Where People Live: Person–Environment Interactions 127 5.1 Describing Person–Environment Interactions 128
COMPETENCE AND ENVIRONMENTAL PRESS 129
Discovering Development: What’s Your Adaptation Level? 131
PREVENTIVE AND CORRECTIVE PROACTIVITY (PCP) MODEL 131 STRESS AND COPING FRAMEWORK 132 COMMON THEORETICAL THEMES AND EVERYDAY COMPETENCE 133
Adult Development in Action 134
5.2 The Ecology of Aging: Community Options 134 AGING IN PLACE 135 DECIDING ON THE BEST OPTION 136 HOME MODIFICATION 137 ADULT DAY CARE 137 CONGREGATE HOUSING 139 ASSISTED LIVING 139
Adult Development in Action 141
5.3 Living in Nursing Homes 141 TYPES OF NURSING HOMES 141
Current Controversies: Financing Long-Term Care 142
WHO IS LIKELY TO LIVE IN NURSING HOMES? 143 CHARACTERISTICS OF NURSING HOMES 144 SPECIAL CARE UNITS 145 CAN A NURSING HOME BE A HOME? 146 COMMUNICATING WITH RESIDENTS 147
How Do We Know?: Identifying Different Types of Elderspeak in Singapore 148
DECISION-MAKING CAPACITY AND INDIVIDUAL CHOICES 150 NEW DIRECTIONS FOR NURSING HOMES 152
Adult Development in Action 153
Social Policy Implications 153
SUMMARY 154 REVIEW QUESTIONS 155 INTEGRATING CONCEPTS IN DEVELOPMENT 156 KEY TERMS 156 RESOURCES 156
Chapter 6 Attention and Memory 157 6.1 Information Processing and Attention 159
INFORMATION-PROCESSING MODEL 159 ATTENTION: THE BASICS 160
SPEED OF PROCESSING 160 PROCESSING RESOURCES 161
Discovering Development: How Good Are Your Notes? 162
AUTOMATIC AND EFFORTFUL PROCESSING 162
Adult Development in Action 163
6.2 Memory Processes 163 WORKING MEMORY 163 IMPLICIT VERSUS EXPLICIT MEMORY 164 LONG-TERM MEMORY 164 AGE DIFFERENCES IN ENCODING VERSUS RETRIEVAL 166
Adult Development in Action 167
6.3 Memory in Context 167 PROSPECTIVE MEMORY 167
How Do We Know?: Failing to Remember I Did What I Was Supposed to Do 168
SOURCE MEMORY AND PROCESSING OF MISINFORMATION 170 FACTORS THAT PRESERVE MEMORY 171
Adult Development in Action 172
6.4 Self-Evaluations of Memory Abilities 172 ASPECTS OF MEMORY SELF-EVALUATIONS 173 AGE DIFFERENCES IN METAMEMORY AND MEMORY MONITORING 173
Adult Development in Action 174
6.5 Memory Training 174 TRAINING MEMORY SKILLS 174
Adult Development in Action 176
6.6 Clinical Issues and Memory Testing 176 NORMAL VERSUS ABNORMAL MEMORY AGING 177 MEMORY AND PHYSICAL AND MENTAL HEALTH 178
Current Controversies: Concussions and Athletes 178
MEMORY AND NUTRITION 179
Adult Development in Action 180
Social Policy Implications 180
SUMMARY 180 REVIEW QUESTIONS 182 INTEGRATING CONCEPTS IN DEVELOPMENT 183 KEY TERMS 183 RESOURCES 184
Chapter 7 Intelligence, Reasoning, Creativity, and Wisdom 185 7.1 Defining Intelligence 187
INTELLIGENCE IN EVERYDAY LIFE 187
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viii CONTENTS
THE BIG PICTURE: A LIFE-SPAN VIEW 187 RESEARCH APPROACHES TO INTELLIGENCE 189
Discovering Development: How Do People Show Intelligence? 190
Adult Development in Action 190
7.2 Developmental Trends in Psychometric Intelligence 190
THE MEASUREMENT OF INTELLIGENCE 190 PRIMARY AND SECONDARY MENTAL ABILITIES 191 FLUID AND CRYSTALLIZED INTELLIGENCE 192 NEUROSCIENCE RESEARCH AND INTELLIGENCE IN YOUNG AND MIDDLE ADULTHOOD 194 MODERATORS OF INTELLECTUAL CHANGE 195
Current Controversies: Problems in Detecting Education and Life Style Effects on Intellectual Functioning 196
MODIFYING PRIMARY ABILITIES 197
Adult Development in Aging 199
7.3 Qualitative Differences in Adults’ Thinking 199 PIAGET’S THEORY 200 GOING BEYOND FORMAL OPERATIONS: THINKING IN ADULTHOOD 201 INTEGRATING EMOTION AND LOGIC 203
Adult Development in Action 205
7.4 Everyday Reasoning and Problem Solving 205 DECISION MAKING 206
How Do We Know?: Age Differences in Information Search and Decision Making 206
PROBLEM SOLVING 207 EXPERTISE 209 CREATIVITY AND WISDOM 210
Adult Development in Action 212 Social Policy Implications 212
SUMMARY 212 REVIEW QUESTIONS 214 INTEGRATING CONCEPTS IN DEVELOPMENT 214 KEY TERMS 215 RESOURCES 215
Chapter 8 Social Cognition 216 8.1 Stereotypes and Aging 217
CONTENT OF STEREOTYPES 218 AGE STEREOTYPES AND PERCEIVED COMPETENCE 219 ACTIVATION OF STEREOTYPES 220 STEREOTYPE THREAT 221
Current Controversies: Are Stereotypes of Aging Associated with Lower Cognitive Performance? 221
Adult Development in Action 222
8.2 Social Knowledge Structures and Beliefs 223 UNDERSTANDING AGE DIFFERENCES IN SOCIAL BELIEFS 223 SELF-PERCEPTION AND SOCIAL BELIEFS 224
Adult Development in Action 225
How Do We Know?: Age Differences in Self-Perception 225
8.3 Social Judgment Processes 226 IMPRESSION FORMATION 226 KNOWLEDGE ACCESSIBILITY AND SOCIAL JUDGMENTS 228 A PROCESSING CAPACITY EXPLANATION FOR AGE DIFFERENCES IN SOCIAL JUDGMENTS 229 ATTRIBUTIONAL BIASES 230
Adult Development in Action 232
8.4 Motivation and Social Processing Goals 232 PERSONAL GOALS 233 EMOTION AS A PROCESSING GOAL 233 COGNITIVE STYLE AS A PROCESSING GOAL 234
Adult Development in Action 235
8.5 Personal Control 235 MULTIDIMENSIONALITY OF PERSONAL CONTROL 235
Discovering Development: How Much Control Do You Have over Your Cognitive Functioning? 236
CONTROL STRATEGIES 236 SOME CRITICISMS REGARDING PRIMARY CONTROL 237
Adult Development in Action 238
8.6 Social Situations and Social Competence 238 COLLABORATIVE COGNITION 238 SOCIAL CONTEXT OF MEMORY 240
Adult Development in Action 240
Social Policy Implications 240
SUMMARY 241 REVIEW QUESTIONS 242 INTEGRATING CONCEPTS IN DEVELOPMENT 243 KEY TERMS 243 RESOURCES 244
Chapter 9 Personality 245 9.1 Dispositional Traits across Adulthood 247
THE CASE FOR STABILITY: THE FIVE-FACTOR MODEL 248 WHAT HAPPENS TO DISPOSITIONAL TRAITS ACROSS ADULTHOOD? 250
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CONTENTS ix
CONCLUSIONS ABOUT DISPOSITIONAL TRAITS 251
Current Controversies: Intraindividual Change and the Stability of Traits 251
Adult Development in Action 252
9.2 Personal Concerns and Qualitative Stages in Adulthood 252
WHAT’S DIFFERENT ABOUT PERSONAL CONCERNS? 252 JUNG’S THEORY 253 ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT 254 THEORIES BASED ON LIFE TRANSITIONS 258 CONCLUSIONS ABOUT PERSONAL CONCERNS 260
Adult Development in Action 260
9.3 Life Narratives, Identity, and the Self 260
Discovering Development: Who Do You Want to Be When You “Grow Up”? 261
MCADAMS’S LIFE-STORY MODEL 261 WHITBOURNE’S IDENTITY THEORY 262 SELF-CONCEPT AND WELL-BEING 264
How Do We Know?: Well-Being Reflected in Brain Function in Emotion and Depression 265
POSSIBLE SELVES 268 RELIGIOSITY AND SPIRITUAL SUPPORT 268 CONCLUSIONS ABOUT NARRATIVES, IDENTITY, AND THE SELF 270
Adult Development in Action 270
Social Policy Implications 270
SUMMARY 270 REVIEW QUESTIONS 272 INTEGRATING CONCEPTS IN DEVELOPMENT 272 KEY TERMS 273 RESOURCES 273
Chapter 10 Clinical Assessment, Mental Health, and Mental Disorders 274 10.1 Mental Health and the Adult Life Course 276
DEFINING MENTAL HEALTH AND PSYCHOPATHOLOGY 276 A MULTIDIMENSIONAL LIFE-SPAN APPROACH TO PSYCHOPATHOLOGY 277 ETHNICITY, GENDER, AGING, AND MENTAL HEALTH 278
Adult Development in Action 279
10.2 Developmental Issues in Assessment and Therapy 279
AREAS OF MULTIDIMENSIONAL ASSESSMENT 279 FACTORS INFLUENCING ASSESSMENT 280 ASSESSMENT METHODS 281 DEVELOPMENTAL ISSUES IN THERAPY 281
Adult Development in Action 282
10.3 The Big Three: Depression, Delirium, and Dementia 282
DEPRESSION 282 DELIRIUM 287 DEMENTIA 287
Current Controversies: New Diagnostic Criteria for Alzheimer’s Disease 293
How Do We Know?: Training Persons with Dementia to Be Group Activity Leaders 297
Adult Development in Action 301
10.4 Other Mental Disorders and Concerns 301 ANXIETY DISORDERS 301 PSYCHOTIC DISORDERS 302 SUBSTANCE ABUSE 304
Discovering Development: What Substance Abuse Treatment Options Are Available in Your Area? 305
Adult Development in Action 305
Social Policy Implications 305
SUMMARY 306 REVIEW QUESTIONS 308 INTEGRATING CONCEPTS IN DEVELOPMENT 308 KEY TERMS 308 RESOURCES 309
Chapter 11 Relationships 310 11.1 Relationship Types and Issues 311
FRIENDSHIPS 311 LOVE RELATIONSHIPS 314
How Do We Know?: Patterns and Universals of Romantic Attachment Around the World 315
VIOLENCE IN RELATIONSHIPS 316
Adult Development in Action 318
11.2 Lifestyles and Love Relationships 318 SINGLEHOOD 319 COHABITATION 319 GAY AND LESBIAN COUPLES 320 MARRIAGE 321 DIVORCE 325
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x CONTENTS
Current Controversies: Do Marriage Education Programs Work? 326
REMARRIAGE 327 WIDOWHOOD 328
Adult Development in Action 328
11.3 Family Dynamics and the Life Course 328 THE PARENTAL ROLE 329 MIDLIFE ISSUES: ADULT CHILDREN AND CARING FOR AGING PARENTS 332
Discovering Development: Caring for Aging Parents 335
GRANDPARENTHOOD 335
Adult Development in Action 337
Social Policy Implications 337
SUMMARY 338 REVIEW QUESTIONS 340 INTEGRATING CONCEPTS IN DEVELOPMENT 340 KEY TERMS 340 RESOURCES 341
Chapter 12 Work, Leisure, and Retirement 342 12.1 Occupational Selection and Development 343
THE MEANING OF WORK 344 OCCUPATIONAL CHOICE REVISITED 344 OCCUPATIONAL DEVELOPMENT 345 JOB SATISFACTION 347
How Do We Know?: Cross-Cultural Aspects of Teachers’ Job Satisfaction 348
Adult Development in Action 350
12.2 Gender, Ethnicity, and Discrimination Issues 350 GENDER DIFFERENCES IN OCCUPATIONAL SELECTION 351 WOMEN AND OCCUPATIONAL DEVELOPMENT 352 ETHNICITY AND OCCUPATIONAL DEVELOPMENT 353 BIAS AND DISCRIMINATION 353
Current Controversies: Do Women Lean Out When They Should Lean In? 354
Adult Development in Action 356
12.3 Occupational Transitions 356 RETRAINING WORKERS 357 OCCUPATIONAL INSECURITY 357 COPING WITH UNEMPLOYMENT 358
Discovering Development: What Unemployment Benefits Are Available in Your Area? 358
Adult Development in Action 360
12.4 Work and Family 360 THE DEPENDENT CARE DILEMMA 360 JUGGLING MULTIPLE ROLES 361
Adult Development in Action 363
12.5 Leisure Activities 363 TYPES OF LEISURE ACTIVITIES 364 DEVELOPMENTAL CHANGES IN LEISURE 364 CONSEQUENCES OF LEISURE ACTIVITIES 365
Adult Development in Action 366
12.6 Retirement and Work in Late Life 366 WHAT DOES BEING RETIRED MEAN? 366 WHY DO PEOPLE RETIRE? 367 ADJUSTMENT TO RETIREMENT 368 EMPLOYMENT AND VOLUNTEERING 369
Adult Development in Action 370
Social Policy Implications 370
SUMMARY 371 REVIEW QUESTIONS 372 INTEGRATING CONCEPTS IN DEVELOPMENT 373 KEY TERMS 373 RESOURCES 374
Chapter 13 Dying and Bereavement 375 13.1 Definitions and Ethical Issues 376
SOCIOCULTURAL DEFINITIONS OF DEATH 376 LEGAL AND MEDICAL DEFINITIONS 377 ETHICAL ISSUES 378
Current Controversies: The Terri Schiavo Case 380
THE PRICE OF LIFE-SUSTAINING CARE 382
Adult Development in Action 383
13.2 Thinking About Death: Personal Aspects 383
Discovering Development: A Self-Reflective Exercise on Death 383
A LIFE-COURSE APPROACH TO DYING 383 DEALING WITH ONE’S OWN DEATH 384 DEATH ANXIETY 385
Adult Development in Action 387
13.3 End-of-Life Issues 387 CREATING A FINAL SCENARIO 387 THE HOSPICE OPTION 388 MAKING YOUR END-OF-LIFE INTENTIONS KNOWN 390
Adult Development in Action 392
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CONTENTS xi
13.4 Surviving the Loss: The Grieving Process 392 THE GRIEF PROCESS 392 NORMAL GRIEF REACTIONS 394 COPING WITH GRIEF 395
How Do We Know?: Grief Processing and Avoidance in the United States and China 396
COMPLICATED OR PROLONGED GRIEF DISORDER 397 ADULT DEVELOPMENTAL ASPECTS OF GRIEF 398 CONCLUSION 400
Adult Development in Action 400
Social Policy Implications 400
SUMMARY 401 REVIEW QUESTIONS 403 INTEGRATING CONCEPTS IN DEVELOPMENT 403 KEY TERMS 403 RESOURCES 404
Chapter 14 Successful Aging 405 14.1 Demographic Trends and Social Policy 406
DEMOGRAPHIC TRENDS: 2030 407 SOCIAL SECURITY AND MEDICARE 409
Current Controversies: What to Do About Social Security and Medicare 413
Adult Development in Action 414
14.2 Health Issues and Quality of Life 414 HEALTH PROMOTION AND QUALITY OF LIFE 414 A FRAMEWORK FOR MAINTAINING AND ENHANCING COMPETENCE 415 HEALTH PROMOTION AND DISEASE PREVENTION 416 LIFESTYLE FACTORS 418
Adult Development in Action 422
14.3 Successful Aging 422
Discovering Development: What Is Successful Aging? 422
APPROACHES TO SUCCESSFUL AGING 422 CRITIQUES OF THE SUCCESSFUL AGING FRAMEWORK 423 EPILOGUE 424
SUMMARY 424 REVIEW QUESTIONS 425 INTEGRATING CONCEPTS IN DEVELOPMENT 425 KEY TERMS 425 RESOURCES 426
REFERENCES R-1
NAME INDEX I-1
GLOSSARY/SUBJECT INDEX I-9
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PREFACE xiii
People’s experiences growing older in the 21 st century differ dramatically from their parents’ and grandpar- ents’ experience. The complex issues confronting indi- viduals and societies are the reason a solid grounding in research and theory about adult development and aging is essential for even understanding news events. The health care debates from 2009 to the present bring many issues to the forefront, including Medicare, end- of-life issues, and longevity and the possibility of signifi- cant intergenerational policy issues. Other news stories about genetic breakthroughs, stem cell research, brain- imaging techniques, and the latest breakthroughs in treating dementia happen regularly. To understand why these issues are so critical, one must understand aging in a broader, rapidly changing context. That is why Adult Development and Aging is now in its seventh edition.
The first few decades of this century will witness a fundamental change in the face of the population— literally. Along with many countries in the industrialized world, the United States will experience an explosive growth in the older adult population due to the aging of the baby-boom generation. Additionally, the propor- tion of older adults who are African American, Latino, Asian American, and Native American will increase rapidly. To deal with these changes, new approaches need to be created through the combined efforts of people in many occupations—academics, gerontolo- gists, social workers, health care professionals, finan- cial experts, marketing professionals, teachers, factory workers, technologists, government workers, human service providers, and nutritionists, to mention just a few. Every reader of this book, regardless of his or her area of expertise, needs to understand older adults in order to master the art of living.
This seventh edition of Adult Development and Aging continues to provide in-depth coverage of the major issues in the psychology of adult development and aging. The seventh edition adds numerous topics and provides expanded coverage of many of the ones discussed in earlier editions.
Changes in Adult Development and Aging Seventh Edition A new feature, Adult Development in Action , chal- lenges students to think critically about decisions they might make as career professionals such as health care workers, gerontologists, and activities directors.
We also include more glossary terms highlighted throughout each chapter to increase accessibility and provide additional study tools.
Chapter-by-Chapter Additions and Enhancements
Chapter 1 Introduces “emerging adulthood,” the period
between adolescence and full adulthood.
Chapter 2 “Neuroimaging Techniques” explains how and
why the ability to see inside the brain of living people has revolutionized our understanding of relations between the brain and our behavior.
Increased explanation of the distinctions between structural neuroimaging and functional neuroimaging.
Description of the brain’s structure includes expla- nation of neurons, dendrites, axon, neurofibers, terminal branches, neurotransmitters, and synapse.
A new diagram of a neuron illustrates dendrites, axon, neurofibers, and terminal branches.
“What Age-Related Changes Occur in Neurons?” discusses the decrease in neurons as the brain declines.
Increased discussion on neurotransmitters, their involvement in brain processes and cognitive aging especially in Alzheimer’s patients.
The section on “Age-Related Changes in Brain Struc- tures” is enhanced so it now includes a discussion of white matter and the study of its structural health.
Preface
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xiv PREFACE
New to the chapter is “Linking Structural Changes with Executive Functioning” examining older adults’ ability to focus on relevant information and control their thoughts.
“Linking Structural Changes with Memory” raises the question of whether Alzheimer’s is an accelera- tion of aging rather than a separate process.
Another section has been added; “Linking Struc- tural Changes with Emotion”
“How Do We Know?: The Aging Emotional Brain” studies Winecoff ’s research findings.
“Linking Structural Changes with Socio-economic Cognition” examines how the aging brain pro- cesses complex situations such as those involving moral judgment.
“Complex Development in the Prefrontal Cortex” examines the critical role of the prefrontal cortex plays on human behavior.
Investigation of how older adults attempt to com- pensate for age-related changes to the brain.
“The Parieto-Frontal Integration Theory” exam- ines the notion that intelligence comes from a dis- tributed and integrated network of neurons in the parietal and frontal areas of the brain.
“Theories of Brain-Behavior Changes Across Adulthood” includes discussion of the HAROLD, CRUNCH, STAC methods.
Section 2.4 “Neural Plasticity and the Aging Brain” has been significantly revised to include informa- tion on how nutrition influences brain changes and cognitive activity.
“Current Controversies: Are Neural Stem Cells the Solution to Brain Aging?”
“Social Policy Implications” asserts the importance of policymakers supporting neuroscience research.
Chapter 3 Discussion of how chronic stress can accelerate
changes in telomeres while moderate exercise can actually slow the rate at which telomeres shorten.
Discussion and accompanying figure of cardiovas- cular disease as the leading cause of death in the United States.
Cardiovascular health as it relates to ethnicity. The factors leading to hypertension including
heredity, sodium intake, and obesity. Menopausal hormone therapy and how decreasing
levels of estrogen can contribute to osteoporosis, urinary incontinence, and cardiovascular disease.
Updated “Current Controversies: Menopausal Hor- mone Therapy” now discusses the circumstances under which a physician might recommend HRT.
The nervous system builds on the age-related changes to the brain discussed in chapter 2 .
“Social Policy Implications” discusses preventing falls.
Chapter 4 New examples of how self-ratings of health reflect
socio-economic background. Enhanced discussion of how psychoneuroimmu-
nology is being used as a framework to predict health outcomes.
New discussion of the way Verbrugge and Jette’s model is being used to identify disability in China.
“How Does Disability in Older Adults Differ Glob- ally?” discusses how adults with disabilities or func- tional limitations are on the rise around the world.
Chapter 5 New section titled “Preventive and Corrective
Proactivity (PCP) Model.” Additional key words: preventative and corrective
adaptations. New discussion on high-tech approaches to home
modification, including “Granny pods.” A discussion of “elderspeak” used in nursing homes. “How Do We Know?: Identifying different types of
elderspeak in Singapore.”
Chapter 6 New Chapter opening vignette about Harry
Lorayne’s book “Ageless Memory.” Additional emphasis on automatic and effortful
processing.
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PREFACE xv
“Age Differences in Encoding versus retrieval” compares the differences in the attention pro- cesses of older and younger adults.
“Neuroscience Evidence” discusses neuroimag- ing and cognitive neuroscience findings that show age related differences in encoding and retrieval.
Enhanced discussion on memory includes a study of differences in age with regard to prospective memory, evidence of how memory changes across adulthood, and information on ways to preserve memory as we age.
“How Do We Know? : Failing to Remember I Did What I Was Supposed to Do.”
Discussion of memory self-efficacy, the belief one will be able to perform a specific task.
Stronger discussion of memory and health includes physical implications like temporary global amnesia.
New “Current Controversies : Concussions and Athletes.”
Chapter 7 “Neuroscience Research and Intelligence in Young
and Middle Adulthood.” Discussion of the neural efficiency hypothesis
that intelligent people process information more efficiently.
“How Do We Know?: Age Differences in Informa- tion Search and Decision Making.”
Chapter 8 “Self-Perception and Social Beliefs” examines our
self-perception of aging. “Attributional Biases” examines whether there are
age differences in the tendency to rely more on dispositional attributions, situational attributions, or a combination of both when making casual attributions.
Chapter 9 “How Do We Know?: Well-being reflected in brain
function in emotion and depression.”
Social Policy Implications now has discussion of interaction between government policy and the experience of aging.
Chapter 10 New figure: Action of beta-amyloid and tau pro-
teins in relation to neurons. Discussion of proposed new diagnostic criteria for
Alzheimer’s disease. New figure: 12 -month prevalence of depression
among all U.S. residents by age. New figure: Clinical continuum of Alzheimer’s
disease showing types of changes over time.
Chapter 11 New figure on the vulnerability-stress-adaptation
model. New figure: Family expenditures on a child, by
income level and age of child, 2011. “Current Controversies : New Diagnostic Criteria
for Alzheimer’s Disease.”
Chapter 12 “Current Controversies: Do women lean out when
they should lean in?” Updated discussion about unemployment during/
after the Great Recession.
Chapter 13 Expanded discussion on “brain death” and how
it is perceived in both the medical profession and also religion.
“Discovering Development: A Self-Reflective Exercise on Death.”
Discussion of neuroimaging research about death anxiety.
Discussion of insurance coverage with regard to Hospice.
“Patient Self-Determination and Competency Eval- uation” describes the Patient Self-Determination Act and why financial reimbursement for indi- vidual physician’s discussion with patients about this issue was not included in the Affordable Care Act 2010.
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xvi PREFACE
‘‘ How Do We Know?: Grief Processing and Avoid- ance in the United States and China.”
New discussion about college students and the expression of grief.
Chapter 14 Discussion of the dependency ratio. Expanded discussion of Social Security and pro-
posals for reform. “Current Controversies: What to do about Social
Security and Medicare.” New discussion of the way age impacts metabolism. “Approaches to Successful Aging” further empha-
sizes Vaillant’s model.
Writing Style
Although Adult Development and Aging covers com- plex issues and difficult topics, we use clear, concise, and understandable language. All terms were exam- ined to ensure their use is essential; otherwise, they were eliminated.
The text is aimed at upper-division undergraduate students. Although it will be helpful if students completed an introductory psychology or life-span human develop- ment course, the text does not assume this background. Instructional Aids
The many pedagogical aids in the sixth edition have been retained and enhanced in the seventh edition.
Learning Aids in the Chapter Text. Each chapter begins with a chapter outline. At the start of each new section, learning objectives are presented. These objectives are keyed to each primary subsection that follows, and they direct the students’ attention to the main points to be discussed. At the conclusion of each major section are concept checks, one for each primary subsection, that help students spot-check their learning. Key terms are defined in context; the term itself is printed in boldface, with the sentence containing the term’s definition in italic.
End-of-Chapter Learning Aids. At the end of each chapter are summaries, organized by major sections and primary subsection heads. This approach helps students match the chapter outline with the summary. Numerous review questions,
also organized around major sections and pri- mary subsections, are provided to assist students in identifying major points. Integrative questions are included as a way for students to link concepts across sections within and across chapters. Key terms with definitions are listed.
Boxes. Three types of boxes are included. Those titled How Do We Know? draw attention to specific research studies that were discussed briefly in the main body of the text. Details about the study’s design, participants, and outcomes are presented as a way for students to connect the informa- tion about these issues in Chapter 1 with specific research throughout the text. Current Contro- versies boxes raise controversial and provocative issues about topics discussed in the chapter. These boxes get students to think about the implications of research or policy issues and may be used effec- tively as points of departure for class discussions. Discovering Development boxes give students a way to see developmental principles and concepts in the “real world” as well as some suggestions on how to find others. These boxes provide a starting point for applied projects in either individual or group settings, and help students understand how devel- opment is shaped by the interaction of biological, psychological, sociocultural, and life-cycle forces.
Instructor Companion Site
Everything you need for your course in one place! This collection of book-specific lecture and class tools is available online via www.cengage.com/login. Access and download an instructor’s manual, test bank, and PowerPoint slides. Cengage Learning Testing Powered by Cognero
The Test Bank is also available through Cognero, a flexible, online system that allows you to author, edit, and manage test bank content as well as create multiple test versions in an instant. You can deliver tests from your school’s learning management system, your class- room, or wherever you want.
Acknowledgments As usual, it takes many people to produce a textbook; such is the case with the seventh edition. The editorial group at Cengage is excellent.
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PREFACE xvii
I also want to thank the reviewers of the seventh edition, who provided extremely helpful and insightful commentary that improved the book: Leslie Adams Lariviere , Assumption College; Sandra Arntz , Carroll University; Hallie Baker , Muskingum University; Anita Glee Bertram , University of Central Oklahoma; Casey Catlin , University of Nevada-Reno; Lisa Connolly , University of Indianapolis; Alissa Dark-Freudeman , UNC-Wilmington; Mary Dolan , CSU San Bernardino; Lisa Emery , Appalachian State University; Daniella Errett , Pennsylvania Highlands Community College; Carolyn Grasse-Backman , Penn State-Harrisburg; Regina Hughes , Collin College; Bonnie Kin , Brenau University; Ryan Leonard , Gannon University; Donna Makowiecki , Holy Family
University-Philadelphia; Sara Margolin , SUNY- Brockport; George Martinez , Somerset Community College; Rick Scheidt , Kansas State University; Gail Spessert , Frederick Community College, Carroll Community College; Virginia Tompkins , Ohio State University-Lima; Marcia Weinstein , Salem State University.
Finally to a group too often overlooked—the sales representatives. Without you, none of this would have any payoff. You are an extension of us and the whole Cengage editorial and production team. What a great group of hard-working folks you are!
Thanks to you all. Live long and prosper!
John C. Cavanaugh
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xviii ABOUT THE AUTHOR
About the Author co-authored, or co-edited 19 books on aging, informa- tion technology, and higher education policy. He is a Past President of Division 20 (Adult Development and Aging) of the American Psychological Association (APA) and is a Fellow of APA (Divisions 1, 2, 3, and 20) and the Gerontological Society of America, and a Charter Fellow of the Association for Psychological Science. He has held numerous leadership positions in these associations, including Chair of the Committee on Aging for APA. He has served on numerous state and national committees for aging-related and higher education organizations. John is a devoted fan of Star Trek and a serious traveler, photographer, backpacker, cook, and chocoholic. He is married to Dr. Christine K. Cavanaugh.
John C. Cavanaugh is President and CEO of the Consortium of Universi- ties of the Washington Metropolitan Area. Pre- viously, he was Chancel- lor of the Pennsylvania State System of Higher Education and President of the University of West Florida. A researcher and teacher of adult develop-
ment and aging for more three decades, he has pub- lished more than 80 articles and chapters and authored,
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Studying Adult Development and Aging
1.1 PERSPECTIVES ON ADULT DEVELOPMENT AND AGING Discovering Development: Myths and Stereotypes about Aging • The Life-Span Perspective • The Demographics of Aging
1.2 ISSUES IN STUDYING ADULT DEVELOPMENT AND AGING The Forces of Development • Interrelations among the Forces: Developmental Influences • Culture and Ethnicity • The Meaning of Age • Core Issues in Development • Current Controversies: Does Personality in Young Adulthood Determine Personality in Old Age?
1.3 RESEARCH METHODS Measurement in Adult Development and Aging Research • General Designs for Research • Designs for Studying Development • How Do We Know?: Conflicts between Cross-Sectional and Longitudinal Data • Integrating Findings from Different Studies • Conducting Research Ethically
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 1
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2 CHAPTER 1
Although Tired and a Bit Unsteady, Diana Nyad Got Out of the Water and Walked Under her Own Power Onto the Beach at Key West, Florida. At age 64 , she had just become the first person ever to swim the 110 miles from Havana, Cuba, to Key West, Florida without the protection of a shark cage. Her feat, completed on September 2, 2013, after more than 50 hours of open water swimming, is just one more in a grow- ing list of accomplishments by people at a point in life once thought to be a time of serious decline in abilities. No more.
From athletes to politicians to people in every- day life, boundaries once thought fixed are being pushed every day. Consider that just since 2008, we have seen the oldest woman ever to compete in swimming in the Olympics, Dara Torres, win Olympic medals at age 41 in Beijing, thus redefin- ing people’s beliefs about world-class athletes and mothers (her daughter was aged two at the time). She won three silver medals, missing a gold by . 01 second . Competing in her fifth Olympic Games, Torres clearly demonstrated that a combination of
great genes and a highly rigorous training regimen enabled her to compete in a sport in which most world-class women swimmers’ careers are over by the time they are in their mid-twenties.
We have also seen Senator John McCain, at age 72 , become the oldest person to be nominated for a first term as president by a major political party. Senator McCain had a long, distinguished career as an officer in the U.S. Navy, was a prisoner of war for 5 years during the Vietnam conflict, and went on to be elected to Congress from Arizona. By his own admission, McCain was in better health than many other people of his age at the time of his campaign. When questioned about his age, he pointed out his 96 - year - old mother, who accompanied him on many of his campaign trips. His (and his mother’s) energy and stamina demonstrated that chronological age alone is a very poor index of people’s capabilities.
Diana Nyad, Dara Torres, and John McCain are great examples of how middle-aged and older adults are being looked at differently today. They showed that adults are capable of doing things thought unimaginable or inappropriate just a few years ago. They also illustrate how the normal changes people experience as they age vary across individuals and why we need to rethink common stereotypes about age.
But there is also an entire generation poised to redefine what growing older really means.
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U.S. long-distance swimmer Diana Nyad is pictured before attempting to swim to Florida from Havana August 31, 2013. Nyad jumped into the calm, turquoise waters of Cuba on Saturday and began making her way towards home, Key West Florida, in pursuit of a dream that she says nearly cost her life during a previous attempt in 2012. Her biggest challenges during the 103 mile (166-km) swim, apart from fatigue, were the poisonous jelly fish that float through the Florida Straits, the sharks, the man o’wars, storms, waves and the powerful and unpredictable Gulf Stream, the mighty ocean current that flows west to east between Cuba and Florida.
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STUDYING ADULT DEVELOPMENT AND AGING 3
The baby-boom generation, consisting of people born between 1946 and 1964, are on average the healthiest and most active generation to begin reaching old age in history. They are not content with playing traditional roles assigned to older adults, and are doing their best to change the way older adults are perceived and treated.
In this chapter, we examine a seemingly simple question: Who are older people? We will see that the answer is more complicated than you might think. We also consider the ways in which geron- tologists study adults and how adults develop.
1.1 Perspectives on Adult Development and Aging LEARNING OBJECTIVES
What is gerontology? How does ageism relate to stereotypes of aging?
What is the life-span perspective? What are the characteristics of the older adult
population? How are they likely to change?
Roberto’s great-grandmother Maria is 89 years old. Maria tells Roberto that when she was a young girl in El Paso, there were very few older women in either her family
or the neighborhood. Roberto knows there are many older people, mostly women, in his own neighborhood, and wonders when and why this changed over her lifetime.
Before you read any more, take a minute and think about your own grandparents or great-grandparents. How would you and other people describe them? Do you want to be like them when you are their age?
We are all headed toward old age. How do you want to be thought of and treated when you get there? Do you look forward to becoming old, or are you afraid about what may lie ahead? Most of us want to enjoy a long life like Maria’s but don’t think much about grow- ing old in our daily lives.
Reading this book will give you the basic facts about growing older. You will learn how to organize these facts by putting them into two contexts: the bio- psychosocial framework and the life-span approach. By the time you are finished, you should have a new, different way of thinking about aging.
You already enjoy a major advantage compared with Maria. She and other people her age did not have the opportunity as young students to learn much about what is typical and what is not typical about aging. Until the last few decades, very little information was avail- able about old age, which people generally thought to be characterized only by decline. Over the past 50 years, though, the science of gerontology , which is the study of aging from maturity through old age, has flourished. As you can imagine from reading the vignette about Dara Torres and John McCain, and as you will see throughout this book, aging reflects the individual differences you have come to expect across people as they change over time. Still, many myths about old people persist. These myths of aging lead to negative stereotypes of older people, which may result in ageism , a form of discrimi- nation against older adults based on their age. Ageism has its foundations in myths and beliefs people take for granted, as well as in intergenerational relations (North & Fiske, 2012). It may be as blatant as believing that all old people are senile and are incapable of making deci- sions about their lives. It may occur when people are impatient with older adults in a grocery store checkout line. Or it may be as subtle as dismissing an older per- son’s physical complaints with the question “What do you expect for someone your age?” As you will learn by doing the activities in the Discovering Development feature, such stereotypes surround us.
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4 CHAPTER 1
This book rebuts these erroneous ideas, but it does not replace them with idealized views of adulthood and old age. Rather, it paints an accurate picture of what it means to grow old today, recognizing that development across adulthood brings growth and opportunities as well as loss and decline. To begin, we consider the life- span perspective, which helps place adult development and aging into the context of the whole human experi- ence. Afterward, we consider the fundamental develop- mental forces, controversies, and models that form the foundation for studying adult development and aging. In particular, we examine the biological, psychological, sociocultural, and life-cycle forces, and the nature–nur- ture and continuity– discontinuity controversies. We consider some basic definitions of age, and you will see that it can be viewed in many different ways. Finally, by examining various research methods we show how the information presented in this book was obtained.
The Life-Span Perspective Imagine trying to understand, without knowing any- thing about his or her life, what your best friend is like. We cannot understand adults’ experiences without appreciating what came before in childhood and ado- lescence. Placing adulthood in this broader context is what the life-span perspective is all about. The life-span perspective divides human development into two phases:
an early phase (childhood and adolescence) and a later phase (young adulthood, middle age, and old age). The early phase is characterized by rapid age-related increases in people’s size and abilities. During the later phase, changes in size are slow, but abilities continue to develop as people continue adapting to the environ- ment (Baltes, Lindenberger, & Staudinger, 2006).
Viewed from the life-span perspective, adult devel- opment and aging are complex phenomena that cannot be understood within the scope of a single disciplinary approach. Understanding how adults change requires input from a wide variety of perspectives. Moreover, aging is a lifelong process, meaning that human devel- opment never stops.
One of the most important perspectives on life- span development is that of Paul Baltes (1987; Baltes et al., 2006), who identified four key features of the life- span perspective:
1. Multidirectionality: Development involves both growth and decline; as people grow in one area, they may lose in another and at different rates. For example, people’s vocabulary ability tends to increase throughout life, but reaction time tends to slow down.
2. Plasticity: One’s capacity is not predetermined or set in concrete. Many skills can be trained or improved with practice, even in late life. There are limits to the degree of potential improvement, however, as described in later chapters.
3. Historical context: Each of us develops within a particular set of circumstances determined by the historical time in which we are born and the cul- ture in which we grow up. Maria’s experiences were shaped by living in the 20 th century in a Chicano neighborhood in southwest Texas.
4. Multiple causation: How people develop results from a wide variety of forces, which we consider later in this chapter. You will see that development is shaped by biological, psychological, sociocul- tural, and life-cycle forces.
The life-span perspective emphasizes that human development takes a lifetime to complete. It sets the stage for understanding the many influences we expe- rience and points out that no one part of life is any more or less important than another.
DISCOVERING DEVELOPMENT: MYTHS AND STEREOTYPES ABOUT AGING We are surrounded by misconceptions of older adults. We have all seen cartoons making jokes about older adults whose memories are poor or whose physical abilities have declined. Most damaging are the ideas portrayed in the media that older adults are incapa- ble of leading productive lives and making a differ- ence. For example, many greeting cards portray older people as having little memory, no teeth, and no desire for sex. As a way to discover something about development, try to find several examples of myths or stereotypes about aging. Look at those greeting cards, cartoons, advertisements, and articles in popu- lar magazines, television shows, and music. Gather as many as you can, and then check them against the research on the topic discussed in this text. By the end of the course, see how many myths and stereotypes you can show to be wrong.
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STUDYING ADULT DEVELOPMENT AND AGING 5
Basing their theories on these principles, Baltes et al. (2006) argue that life-span development consists of the dynamic interactions among growth, maintenance, and loss regulation. In their view, four factors are critical: 1. As people grow older, they show an age-related
reduction in the amount and quality of biologi- cally based resources.
2. There is an age-related increase in the amount and quality of culture needed to generate continuously higher growth. Usually this results in a net slowing of growth as people age.
3. People show an age-related decline in the efficiency with which they use cultural resources.
4. There is a lack of cultural, “old-age friendly” sup- port structures.
Taken together, these four factors create the need to shift more and more resources to maintain function and deal with biologically related losses as we grow old, leaving fewer resources to be devoted to continued growth. As we see throughout this book, this shift in resources has profound implications for experiencing aging and for pointing out ways to age successfully.
The Demographics of Aging Take a look around at the people you see in your everyday life in your hometown. There have never
been as many older adults as there are now, especially people over age 85 . Why? Most important, health care improved during the 20 th century, and many fewer women died during childbirth. Also, one of the larg- est generations ever, the baby boomers, began reaching age 65 . Let’s take a closer look.
Population Trends in the United States. Look closely at the age distributions in the U.S. population for 2000 and projections for 2025, 2050, and 2100. These show that the population is aging (see Fig- ures 1.1 , 1.2 , 1.3 , and 1.4 ). In 2000, there were many more people between their mid - 30 s and 40 s than any other age group. Projections for 2025 (when nearly all the baby boomers will have reached age 65 ) show that the distribution will have changed dramatically; the baby boomers’ aging makes the graph look much more rectangular. By 2050, the shape of the distribution will be more like a beehive, as more people continue to live into their 80 s , 90 s , and 100 s . The biggest change by the year 2100 will be in the number of older men.
The coming dramatic change in the number of older adults has already had profound effects on everyone’s lives. Through the first few decades of the 21 st century, older adults, driven by the baby boomers, will be a major economic and political force. There is legitimate concern that the cost of entitlement programs that support older adults, such as Social Security and other pension systems
Figure 1.1 Resident population of the United States as of July 1, 2000. Source : National Projections Program, Population Division, U.S. Census Bureau, Washington, D.C. 20233.
100� 95–99 90–94 85–89 80–84 75–79 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19 10–14
5–9 Less than 5
5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 5.04.54.03.53.02.52.01.51.00.5
Percentage MALE FEMALE
A g
e
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6 CHAPTER 1
as well as Medicare, will become the largest expenditures in the federal and states’ budgets, forcing intergenera- tional conflict over shrinking public resources. The costs for programs that support older adults will be borne by smaller groups of taxpayers in younger generations.
The strain on health and social services will be exacerbated because the most rapidly growing segment of the U.S. population is people over age 85 . In fact,
the number of such people will increase over threefold between 2010 and 2050 (from about 5.7 million to over 19 million), compared to a much smaller percentage increase in the number of 20 to 29 - year-olds during the same period (from about 42 million to over 56 million) (U.S. Census Bureau, 2012a). As we discuss in Chapter 4 , people over age 85 generally need more assistance with daily living than do people under age 85 .
100� 95–99 90–94 85–89 80–84 75–79 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19 10–14
5–9 Less than 5
5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 5.04.54.03.53.02.52.01.51.00.5
Percentage MALE FEMALE
A g
e
Figure 1.3 Projected resident population of the United states as of July 1, 2050. Source : National Projections Program, Population Division, U.S. Census Bureau, Washington, D.C. 20233.
100� 95–99 90–94 85–89 80–84 75–79 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19 10–14
5–9 Less than 5
5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 5.04.54.03.53.02.52.01.51.00.5
Percentage MALE FEMALE
A g
e
Figure 1.2 Projected resident population of the United States as of July 1, 2025. Source : National Projections Program, Population Division, U.S. Census Bureau, Washington, D.C. 20233.
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STUDYING ADULT DEVELOPMENT AND AGING 7
Diversity of Older Adults in the United States. Just like people your age, older adults are not all alike. The number of older adults among ethnic minority groups is increasing faster than among European Ameri- cans. For example, the number of Native American elderly has increased by nearly two-thirds in recent decades; Asian and Pacific Islander elderly have qua- drupled; older adults are the fastest-growing segment of the African American population; and the number of Latino American elderly is also increasing rapidly (U.S. Census Bureau, 2012a). Projections for the future
diversity of the U.S. population are shown in Figure 1.5 . You should note the very large increases in the number of Asian, Native, and Latino American older adults rel- ative to European and African American older adults.
Future older adults will be better educated. In 2010, a little more than half of the people over age 65 have only a high school diploma or some college, and about 25 % have a bachelor’s degree or higher. By 2030 it is estimated that 85 % will have a high school diploma, and 75 % will have a college degree (U.S. Census Bureau, 2012a). These dramatic changes will be due mainly to
100� 95–99 90–94 85–89 80–84 75–79 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34 25–29 20–24 15–19 10–14
5–9 Less than 5
5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 5.04.54.03.53.02.52.01.51.00.5
Percentage MALE FEMALE
A g
e Figure 1.4 Projected resident population of the United States as of July 1, 2100. Source : National Projections Program, Population Division, U.S. Census Bureau, Washington, D.C. 20233.
European Americans
African Americans
Asian and Native Americans
Hispanic Americans
0
Percentage change
100 200 300 400 500 600 700 800 900
1995–2010
1995–2030
1995–2050
Figure 1.5 Projected growth of minority populations of older adults in the United States 1995–2050. Source : Data from the U.S. Census Bureau.
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8 CHAPTER 1
better educational opportunities for more students and greater need for formal schooling (especially college) to find a good job. Also, better-educated people tend to live longer, mostly because they have higher incomes, which give them better access to good health care and a chance to follow healthier lifestyles. We examine these issues in more detail in Chapter 4 .
You probably know some older adults who are fiercely independent, who view the challenges of aging as something you face mainly alone or with help from professionals. You also probably know others who view themselves as part of a larger unit, typically family, and see the same challenges as something one faces with other family members as a group. In more formal terms, the first group of people represents individualism, and the second group reflects collectivism (Ajrouch, 2008; Phillips, Ajrouch, & Hillcoat-Nalletamby, 2010).
As the number of ethnic minority older adults continues to increase, an important emerging issue will be the differences in these perspectives. This matters because the ways in which intervention is done differ a great deal. For those who emphasize individualism, the emphasis and approach is very much focused on only the person in question. In contrast, intervention with those who fit the collectivism approach needs to include the broader family or even friendship network. As the United States becomes more diverse, these views, which reflect different cultures globally, will increas- ingly need to be taken into account by all organizations.
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Population Trends Around the World. The popu- lation trends in the United States are not unique. As you can see in Figures 1.6 and 1.7 the number of older adults will increase dramatically in nearly all areas of the world over the next several decades. (The figures show the expected changes between 2000 and 2030.) Overall, the “oldest” area of the world will continue to be Europe. The “youngest” area will continue to be Africa, where overall poor access to health care and a high incidence of conflict and AIDS significantly shorten lives (U.S. Census Bureau, 2012b).
Economically powerful countries around the world, such as China, are trying to cope with increased numbers of older adults that strain the country’s resources. Due to China’s one child policy; by 2030 there are projected to be about 20 million more older adults than children under 15 . The economic impact will be significant for China, and in general the aging of the world’s workforce and population in general will have significant effects on the world economy (Krueger & Ludwig, 2007; Tyers & Shi, 2012). For example, pension and health care costs will increase dramatically, and there will be fewer work- ers to bear the burden in many industrialized coun- tries. Canada leads the industrialized world in the rate of increase in the older adult population: between 2000 and 2030, it will increase by 126 %.
But that’s nothing compared to the explosive increase in the population of older adults that faces developing countries (U.S. Census Bureau, 2012b). For example, Egypt, Malaysia, and Singapore will see a fivefold increase in older adults by 2050, with many other countries, such as Brazil (fourfold), also experi- encing very significant increases.
Economic conditions in different countries have a powerful effect on aging. One way to see this is to ask whether the parents of adults in households in devel- oping countries are alive. Given that the parents are over age 50 (if they are alive), the relationship between economic situation and age becomes clearer. Banerjee and Duflo (2010) found that the odds of having a living parent was about the same for all adults whose daily per capita expenditures were $ 4 or less, and increased steadily the higher the daily expenditure got. For example, the probability of having a living parent for adults whose daily expenditures were between $ 6 and $ 10 was 36 percentage points higher than for adults with a daily expenditure of $ 1 or $ 2 . Additionally, for
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STUDYING ADULT DEVELOPMENT AND AGING 9
Figure 1.6 Percentage of people in countries globally aged 65 and over, 2000. Source : U.S. Census Bureau, 2000a.
Figure 1.7 Percentage of people in countries globally aged 65 and over, 2030. Source : U.S. Census Bureau, 2000a.
Less than 3.0
3.0–7.9
8.0–12.9
13.0�
Less than 3.0
3.0–7.9
8.0–12.9
13.0�
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10 CHAPTER 1
people living in India, Indonesia, or Vietnam, the odds that people over age 50 with daily expenditures of $ 1 or $ 2 will die within 5 – 7 years is at least three times greater than it is for people whose daily expenditures are $ 6 – 10 . Clearly, poverty is strongly related to the odds of living a long life.
The worldwide implications of these population shifts are enormous. First, consider what will happen in countries such as Japan and throughout most of Europe, where the changes will result in net popula- tion decreases. Why? The main reason these countries are “aging” is a significantly lower birth rate. Once the large older-adult population dies, population decreases are inevitable. For them, it presents the problem of how their economies will handle a shrinking supply of work- ers (and consumers). In contrast, the dramatic increase in older adults (and population in general) of most of the rest of the world presents the multiple problems of financing the care of more older adults in health care systems that are already inadequate and strained, as well as trying to absorb more older workers in fragile economies (Lloyd, 2012; Phillips & Siu, 2012).
rushed into his mind. He could only imagine the kinds of things Devonna would experience growing up. He hoped that she would have a good neighborhood in which to play and explore her world. He hoped that she inher- ited the family genes for good health. He wondered how Devonna’s life growing up as an African American in the United States would be different from his experiences.
Like many grandparents, Levar wonders what the future holds for his granddaughter. The questions he considers are interesting in their own right, but they are important for another reason: They get to the heart of general issues of human development that have intrigued philosophers and scientists for centuries. You have probably wondered about many similar issues. How do some people manage to remain thin, whereas other people seem to gain weight merely by looking at food? Why do some people remain very active and mentally well into later life? How does growing up in a Spanish-speaking culture affect one’s views of family caregiving? Answering these questions requires us to consider the various forces that shape us as we mature. Developmentalists place special emphasis on four forces: biological, psychological, sociocultural, and life cycle. These forces direct our development much as an artist’s hands direct the course of a painting or sculpture.
Following from the forces that shape adult devel- opment and aging are questions such as: What is the relative importance of genetics and environment on people’s behavior? Do people change gradually, or do they change more abruptly? Do all people change in the same way? These questions reflect controversies that historically underlie the study of human develop- ment (Lerner, 2001): the nature–nurture controversy, the change–stability controversy, the continuity– discontinuity controversy, and the “universal versus context-specific development” controversy.
Having a firm grasp on the forces and controver- sies of development is important because it provides a context for understanding why researchers and theorists believe certain things about aging or why some topics have been researched a great deal and others have been hardly studied at all. For example, someone who believes that a decline in intellectual ability is an innate and inevi- table part of aging is unlikely to search for intervention techniques to raise performance. Similarly, someone who believes that personality characteristics change across adulthood would be likely to search for life transitions.
Adult Development in Action If you were a staff member for your congressional representative, what would you advise with respect to economic and social policy given the demographic changes in the U.S. population?
1.2 Issues in Studying Adult Development and Aging LEARNING OBJECTIVES
What four main forces shape development? What are normative age-graded influences,
normative history-graded influences, and nonnormative influences?
How do culture and ethnicity influence aging? What is the meaning of age? What are the nature–nurture, stability–change,
continuity–discontinuity, and the “universal versus context-specific development” controversies?
Levar Johnson smiled broadly as he held his newborn granddaughter for the first time. So many thoughts
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STUDYING ADULT DEVELOPMENT AND AGING 11
The Forces of Development Gray hair, remembering, activity levels—Why do adults differ so much on these and other things? This question requires us to understand the basic forces that shape us. Developmentalists typically consider four interactive forces (shown in Figure 1.8 ):
1. Biological forces include all genetic and health- related factors that affect development. Examples of biological forces include menopause, facial wrin- kling, and changes in the major organ systems.
2. Psychological forces include all internal percep- tual, cognitive, emotional, and personality factors that affect development. Collectively, psychological forces provide the characteristics we notice about people that make them individuals.
3. Sociocultural forces include interpersonal, societal, cultural, and ethnic factors that affect development. Sociocultural forces provide the overall contexts in which we develop.
4. Life-cycle forces reflect differences in how the same event or combination of biological, psychological, and sociocultural forces affects people at different points in their lives. Life-cycle forces provide the context for the developmental differences of inter- est in adult development and aging.
life-cycle forces, the biopsychosocial framework pro- vides a complete overview of the shapers of human development. Each of us is a product of a unique com- bination of these forces. Even identical twins growing up in the same family eventually have their own unique friends, partners, occupations, and so on. To see why all these forces are important, imagine that we want to know how people feel about forgetting. We would need to consider several biological factors, such as whether the forgetting was caused by an underlying disease. We would want to know about such psychological factors as what the person’s memory ability has been through- out his or her life and about his or her beliefs about what happens to memory with increasing age. We would need to know about sociocultural factors, such as the influence of social stereotypes about forgetting. Finally, we would need to know about the age of the person when a forgetting experience occurs. Focusing on only one (or even two or three) of the forces would provide an incomplete view of how the person feels. The biopsychosocial framework, along with life-cycle forces, will provide a way to understand all the devel- opmental outcomes you will encounter in this text.
Interrelations among the Forces: Developmental Influences
All the forces we have discussed combine to create people’s developmental experiences. One way to con- sider these combinations is to consider the degree to which they are common or unique to people of spe- cific ages. An important concept in this approach is cohort. A cohort is a group of people born at the same point or specific time span in historical time. So every- one born in 1995 would be the 1995 cohort; similarly, those born between 1946 and 1964 represent the baby- boom cohort. Based on this approach, Baltes (1987; Baltes et al., 2006) identifies three sets of influences that interact to produce developmental change over the life- span: normative age-graded influences, normative his- tory-graded influences, and nonnormative influences.
Normative age-graded influences are experiences caused by biological, psychological, and sociocultural forces that occur to most people of a particular age . Some of these, such as puberty, menarche, and menopause, are biological. These normative biological events usually indicate a major change in a person’s life; for example, menopause is an indicator that a woman can
Figure 1.8 The biopsychosocial framework shows that human development results from interacting forces.
Psychological forces
Biological forces
Sociocultural forces
Life- cycle forces
Person
One useful way to organize the biological, psychologi- cal, and sociocultural forces on human development is with the biopsychosocial framework . Together with
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12 CHAPTER 1
no longer bear children without medical intervention. Normative psychological events include focusing on certain concerns at different points in adulthood, such as a middle-aged person’s concern with socializing the younger generation. Other normative age-graded influences involve sociocultural forces, such as the time when first marriage occurs and the age at which someone retires. Normative age-graded influences typically correspond to major time-marked events, which are often ritualized. For example, many younger adults formally celebrate turning 21 as the official tran- sition to adulthood, getting married typically is sur- rounded with much celebration, and retirement often begins with a party celebrating the end of employment. These events provide the most convenient way to judge where we are on our social clock.
Normative history-graded influences are events that most people in a specific culture experience at the same time . These events may be biological (such as epidemics), psychological (such as particular stereo- types), or sociocultural (such as changing attitudes toward sexuality). Normative history-graded influ- ences often give a generation its unique identity, such as the baby-boom generation, generation X (people born roughly between 1965 and 1975), and the millen- nial generation (sometimes called the Echo Boomers or generation Y, born between 1979 and 1994). These influences can have a profound effect across all gen- erations. For example, the attacks on the World Trade Center on September 11, 2001, fundamentally changed attitudes about safety and security that had been held for decades.
Nonnormative influences are random or rare events that may be important for a specific individual but are not experienced by most people. These may be favor- able events, such as winning the lottery or an election, or unfavorable ones, such as an accident or layoff. The unpredictability of these events makes them unique. Such events can turn one’s life upside down overnight.
Life-cycle forces are especially key in understand- ing the importance of normative age-graded, norma- tive history-graded, and nonnormative influences. For example, history-graded influences may produce gen- erational differences and conflict; parents’ and grand- parents’ experiences as young adults in the 1960s and 1970s (before AIDS, smartphones, and global terror- ism) may have little to do with the complex issues faced
by today’s young adults. In turn, these interactions have important implications for understanding differ- ences that appear to be age related. That is, differences may be explained in terms of different life experiences (normative history-graded influences) rather than as an integral part of aging itself (normative age-graded influences). We will return to this issue when we dis- cuss age, cohort, and time-of-measurement effects in research on adult development and aging.
Culture and Ethnicity Culture and ethnicity jointly provide status, social set- tings, living conditions, and personal experiences for people of all ages, and they influence and are influenced by biological, psychological, and life-cycle developmen- tal forces. Culture can be defined as shared basic value orientations, norms, beliefs, and customary habits and ways of living. Culture provides the basic worldview of a society in that it gives it the basic explanations about the meanings and goals of everyday life (Matsumoto & Juang, 2013). Culture is such a powerful influence because it connects to biological forces through family lineage, which is sometimes the way in which mem- bers of a particular culture are defined. Psychologically, culture shapes people’s core beliefs; in some cases this can result in ethnocentrism, or the belief that one’s own culture is superior to others. Being socialized as a child within a culture usually has a more profound effect on a person than when one adopts a culture later in life, resulting in significant life-cycle timing effects. Culture is extremely important in gerontology because how people define basic concepts such as person, age, and life course varies a great deal across cultures.
Equally important is the concept of ethnicity, which is an individual and collective sense of identity based on historical and cultural group membership and related behaviors and beliefs (Matsumoto & Juang, 2013). Compared with culture, ethnic group identities have both solid and fluid properties, reflecting the fact that there are both unchanging and situation-specific aspects to ethnic identity (Jaspal & Cinnirella, 2012). An example of these properties is that the terms refer- ring to an ethnic group can change over time; for exam- ple, the terms colored people, Negroes, black Americans, and African Americans have all been used to describe Americans of African ancestry. Ethnic identity is first influenced by biology through one’s parents. However,
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STUDYING ADULT DEVELOPMENT AND AGING 13
how one incorporates ethnic identity depends on numerous psychological factors as well as age.
Both culture and ethnicity are key dimensions along which adults vary. However, we know very little about how culture or ethnicity affects how people expe- rience old age. Throughout the rest of this book, we explore areas in which culture and ethnicity have been studied systematically. Unfortunately, most research focuses only on European Americans. Given the demo- graphic trends discussed earlier, this focus must change so we can understand the experience of growing older in the United States in the next few decades.
The Meaning of Age When you are asked the question “How old are you?” what crosses your mind? Is it the number of years since the day of your birth? Is it how old you feel at that time? Is it defined more in terms of where you are bio- logically, psychologically, or socially than in terms of calendar time? You may not have thought about it, but age is not a simple construct (and in the case of people such as the !Kung, it has no meaning at all).
Likewise, aging is not a single process. Rather, it consists of at least three distinct processes: primary, secondary, and tertiary aging (Birren & Cunningham, 1985). Primary aging is normal, disease-free develop- ment during adulthood. Changes in biological, psy- chological, sociocultural, or life-cycle processes in primary aging are an inevitable part of the develop- mental process; examples include menopause, decline
in reaction time, and the loss of family and friends. Most of the information in this book represents pri- mary aging. Secondary aging is developmental changes that are related to disease, lifestyle, and other environ- mentally induced changes that are not inevitable (e.g., pollution). The progressive loss of intellectual abilities in Alzheimer’s disease and related forms of demen- tia are examples of secondary aging. Finally, tertiary aging is the rapid losses that occur shortly before death. An example of tertiary aging is a phenomenon known as terminal drop, in which intellectual abilities show a marked decline in the last few years before death.
Everyone does not grow old in the same way. Whereas most people tend to show usual patterns of aging that reflect the typical, or normative, changes with age, other people show highly successful aging in which few signs of change occur. For example, although most people tend to get chronic diseases as they get older, some people never do. What makes people who age successfully different? At this point, we do not know for sure. It may be a unique combination of genetics, optimal environment, flexibility in dealing with life situations, a strong sense of personal control, and maybe a bit of luck. For our present discussion, the main point to keep in mind is that everyone’s experi- ence of growing old is somewhat different. Although many people develop arthritis, how each person learns to cope is unique.
When most of us think about age, we usually think of how long we have been around since our birth; this way of defining age is known as chronological age. Chronological age is a shorthand way to index time and organize events and data by using a commonly understood standard: calendar time. Chronological age is not the only shorthand index variable used in adult development and aging. Gender, ethnicity, and socioeconomic status are others. No index variable itself actually causes behavior. In the case of gender, for example, it is not whether a person is male or female per se that determines how long he or she will live on average but rather the underlying forces, such as hormonal effects, that are the true causes. This point is often forgotten when age is the index variable, per- haps because it is so familiar to us and so widely used. However, age (or time) does not directly cause things to happen, either. Iron left out in the rain will rust, but rust is not caused simply by time. Rather, rust is a
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14 CHAPTER 1
time-dependent process involving oxidation in which time is a measure of the rate at which rust is created. Similarly, human behavior is affected by experiences that occur with the passage of time, not by time itself. What we study in adult development and aging is the result of time- or age-dependent processes, not the result of age itself.
Describing a person’s age turns out to be quite complicated. Here’s why. Perceived age refers to the age you think of yourself as. The saying “You’re only as old as you feel” captures perceived age. Where people are, relative to the maximum number of years they could possibly live, is their biological age. Biological age is assessed by measuring the functioning of the various vital, or life-limiting, organ systems, such as the car- diovascular system.
Psychological age refers to the functional level of the psychological abilities people use to adapt to chang- ing environmental demands. These abilities include memory, intelligence, feelings, motivation, and other skills that foster and maintain self-esteem and personal control.
Finally, sociocultural age refers to the specific set of roles individuals adopt in relation to other members of the society and culture to which they belong. Socio- cultural age is judged on the basis of many behaviors and habits, such as style of dress, customs, language, and interpersonal style. Sociocultural age is especially important in understanding many of the family and work roles we adopt. When to get married, have chil- dren, make career moves, retire, and so on often are influenced by what we think our sociocultural age is. Such decisions also play a role in determining our self-esteem and other aspects of personality. Many of the most damaging stereotypes about aging (e.g., that older people should not have sex) are based on faulty assumptions about sociocultural age.
A good example of the complexities of age is the concept of emerging adulthood. Some human devel- opmentalists view the period from the late teens to the mid- to late 20 s as emerging adulthood , a period when individuals are not adolescents but are not yet fully adults (Arnett, 2012). Emerging adulthood is a time to explore careers, self-identity, and commitments. It is also a time when certain biological and physiologi- cal developmental trends peak, and brain development continues in different ways.
In sum, a person’s age turns out to be quite com- plex. Think about yourself. You probably have days when even though the calendar says you’re a certain age, your exploits the day before resulted in your feel- ing much younger at the time and much older the next morning. How “old” anyone is can change from one moment to the next.
Core Issues in Development Is it your genes or experiences that determine how intelligent you are? If a young adult woman is outgo- ing, does this mean she will be outgoing in late life? If people change, is it more gradual or sporadic? Is aging the same around the world? These and similar ques- tions have occupied some of the greatest Western phi- losophers in history: Plato, Aristotle, René Descartes, John Locke, and Ludwig Wittgenstein, among many others. Four main issues occupy most of the discus- sion: nature versus nurture, stability versus change, continuity versus discontinuity, and universal versus context-specific development. Because each of these issues cuts across the topics we discuss in this book, let’s consider each briefly.
The Nature–Nurture Issue. Think for a minute about a particular characteristic that you and several people in your family have, such as intelligence, good looks, or a friendly, outgoing personality.
Why is this trait so prevalent? Is it because you inherited the trait from your parents? Or is it because of where and how you and your parents were brought up? Answers to these questions illustrate different posi- tions on the nature–nurture issue , which involves the degree to which genetic or hereditary influences (nature) and experiential or environmental influences (nurture) determine the kind of person you are. Scientists once hoped to answer these questions by identifying either heredity or environment as the cause of a particular aspect of development. The goal was to be able to say, for example, that intelligence was due to heredity or that personality was due to experience. Today, however, we know that virtually no features of life-span develop- ment are due exclusively to either heredity or environ- ment. Instead, development is always shaped by both: Nature and nurture are mutually interactive influences.
For example, it is known that some forms of Alzheimer’s disease are genetically linked. However,
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STUDYING ADULT DEVELOPMENT AND AGING 15
whether one actually gets Alzheimer’s disease, and possibly even how the disease progresses, may be influenced by the environment. Specifically, an envi- ronmental trigger may be needed for the disease to occur. Moreover, evidence indicates that providing a supportive environment for people with Alzheimer’s disease improves their performance on cognitive tasks (Hunter, Ward, & Camp, 2012).
So in order to understand a newborn’s future we must simultaneously consider his or her inborn, hered- itary characteristics and the environment. Both fac- tors must be considered together to yield an adequate account of why we behave the way we do. To explain a person’s behavior and discover where to focus inter- vention, we must look at the unique interaction for that person between nature and nurture.
The Stability–Change Issue. Ask yourself the fol- lowing question: Are you pretty much the same as you were 10 years ago, or are you different? How so? Depending on what aspects of yourself you considered, you may have concluded that you are pretty much the same (perhaps in terms of learning style) or that you are different (perhaps in some physical feature such as weight). The stability–change issue concerns the degree to which people remain the same over time, as discussed in the Current Controversies feature. Stability at some basic level is essential for us (and others) to recognize that one is the same individual as time goes on. But we also like to believe that our characteristics are not set in concrete, that we can change ourselves if we so desire. (Imagine not being able to do anything to rid yourself of some character defect.)
Although there is little controversy about whether children change in some ways from birth through age 18 , there is much controversy about whether adults do as well. Much of the controversy over stability and change across adulthood stems from how specific char- acteristics are defined and measured. How much we remain the same and how much we change, then, turns out to be a difficult issue to resolve in an objective way. For many gerontologists, whether stability or change is the rule depends on what personal aspect is being con- sidered and what theoretical perspective one is adopting.
The Continuity–Discontinuity Controversy. The third major issue in developmental psychology is a
CURRENT CONTROVERSIES: DOES PERSONALITY IN YOUNG ADULTHOOD DETERMINE PERSONALITY IN OLD AGE? Lest you think the controversies underlying adult development and aging do not reflect ongoing debate, consider the case of personality in adult- hood. Perhaps no other topic in gerontology has resulted in such heated debates as whether people’s basic personality remains the same throughout adulthood or undergoes fundamental change. As we explore in detail in Chapter 9 , numerous theories have been developed just to account for the data on this one topic.
Consider yourself and other adults you know. Is the person labeled “class clown” in high school likely to be as much of a fun-loving person 10 , 20 , or 30 years later? Will the shy person who would never ask anyone to dance be as withdrawn? Or will these people be hardly recognizable at their various class reunions? Probably in your experience you’ve encountered both outcomes; that is, some people seem to remain the same year after year, whereas some people seem to undergo tremendous change. Why is that?
For one thing, it depends on how specific you get in looking at aspects of a person’s personality. In the case of a very specific trait, such as shyness, you will probably see overall stability across adulthood. But if you look at a more global aspect such as the degree to which a person is concerned with the next generation, then you are more likely to find change.
What does this mean? Certainly, it means you have to be very careful in making general statements about stability or change. It also means you have to be quite specific about what you are interested in measuring and at what level of complexity. We will encounter many more examples of both stability and change throughout the book that reflect both these needs.
derivative of the stability–change controversy. The continuity– discontinuity controversy concerns whether a particular developmental phenomenon represents a smooth progression over time (continuity) or a series of abrupt shifts (discontinuity). Continuity approaches usually focus on the amount of a characteristic a person has, whereas discontinuity approaches usually focus on the kinds of characteristics a person has. Of course, on
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16 CHAPTER 1
a day-to-day basis, behaviors often look nearly identi- cal, or continuous. But when viewed over the course of many months or years, the same behaviors may have changed dramatically, reflecting discontinuous change. Throughout this book, you will find examples of devel- opmental changes that appear to be more on the con- tinuities side and ones that appear to be more on the discontinuities side.
An example of continuity is discussed in Chapter 6 : reaction time. As people grow older, the speed with which they can respond slows down. But in Chapters 8 you will read about an example of discontinuity: How people approach problems, especially ones with com- plex and ambiguous features, undergoes fundamental shifts from young adulthood through middle age.
Within the discontinuity view lies the issue of how adaptable people are in situations as they age. Baltes and colleagues (1998; Baltes et al., 1999) use the term plasticity to describe this in relation to people’s capac- ity. Plasticity refers to the belief that capacity is not fixed, but can be learned or improved with practice. For example, people can learn ways to help them- selves remember information, which in turn may help them deal with declining short-term memory ability with age. Although plasticity can be demonstrated in many arenas, there are limits to the degree of potential improvement, as we will see in later chapters.
The Universal versus Context-Specific Development Controversy. The universal versus context-specific development controversy concerns whether there is just one path of development or several. Consider the !Kung tribe, who live in the Kalahari Desert of Botswana in southwest Africa (Lee, Hitchcock, & Biesele, 2002). If you were to ask an older !Kung “How old are you?” you would quickly learn that the question has no meaning. !Kung also do not keep track of the number of years they have been alive, the number of children they have, or how often they move. !Kung mothers can describe in detail each of their children’s births, but they leave it to others to figure out how many children this adds up to. To the !Kung, age per se is unimportant; when asked to describe people who are “younger” or “older,” they give the names of specific people. Social roles among the !Kung also do not differ by age; for example, women in their 20 s and 60 s all tend gardens, draw water from wells, and take care of children.
Life among !Kung adults contrasts sharply with life among adults in the United States, where age matters a great deal and social roles differ accordingly. Can one theory explain development in both groups? Maybe. Some theorists argue that such differences are more apparent than real and that development worldwide reflects one basic process for everyone. According to this view, differences in development are simply varia- tions on a fundamental developmental process, much as Hershey, Nestlé, Teuscher, and Godiva chocolates are all products of the same basic manufacturing process.
The opposing view is that differences between people may not be just variations on a theme. Advo- cates of this view argue that adult development and aging are inextricably intertwined with the context in which they occur. A person’s development is a prod- uct of complex interactions with the environment, and these interactions are not fundamentally the same in all environments. Each environment has its own set
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STUDYING ADULT DEVELOPMENT AND AGING 17
of unique procedures that shape development, just as the “recipes” for chocolates, computers, and pens have little in common.
The view adopted in this book is that adult devel- opment and aging must be understood within the con- texts in which they occur. In some cases, this means that contexts are sufficiently similar that general trends can be identified. In others, such as the !Kung and U.S. societies, these differences prevent many general state- ments. In Levar’s case with his granddaughter, it may be a blend of the two.
That’s what we will be considering in this section—the tools that gerontologists have used for decades in dis- covering the secrets of adult development and aging.
This section is so important that if you have trou- ble understanding the information after reading it a few times, ask your instructor.
So suppose Leah and Sarah know that you’re taking a course in adult development and aging, and they ask you to settle the matter. You know research could show whose approach is better under what circumstances, but how? Gerontologists must make several key decisions as they prepare to study any topic. They need to decide how to measure the topic of interest, they must design the study, they must choose a way to study development, and they must respect the rights of the people who will participate in the study.
What makes the study of adult development and aging different from other areas of social science is the need to consider multiple influences on behav- ior. Explanations of development entail consideration of all the forces we considered earlier. This makes research on adult development and aging more diffi- cult, if for no other reason than it involves examining more variables.
Measurement in Adult Development and Aging Research
Researchers typically begin by deciding how to mea- sure the topic of interest. For example, the first step toward resolving Leah and Sarah’s discussion about remembering grocery items would be to decide how to measure remembering. Gerontologists usually use one of three approaches: observing systematically, using tasks to sample behavior, and asking people for self- reports. In addition, researchers need to be concerned with how representative the participants in the study are of the larger group of people in question.
Regardless of the kind of method chosen, research- ers must show it is both reliable and valid. The reliability of a measure is the extent to which it provides a consis- tent index of the behavior or topic of interest. A measure of memory is reliable to the extent that it gives a consis- tent estimate of performance each time you administer it. All measures used in gerontological research must be shown to be reliable, or they cannot be used. The validity of a measure is the extent to which it measures
Adult Development in Action How would understanding the forces and issues that shape human development help you be a better healthcare worker at a neighborhood clinic?
1.3 Research Methods LEARNING OBJECTIVES
What approaches do scientists use to measure behavior in adult development and aging research?
What are the general designs for doing research? What specific designs are unique to adult
development and aging research? What ethical procedures must researchers follow?
Leah and Sarah are both 75 years old and are in fairly good health. They believe their memory is not as good as it once was, so they both use various memory aids: Leah tries to think of images in her mind to remember her grocery list, whereas Sarah writes them down. Leah and Sarah got into a discussion recently about which technique works better.
You might be asking yourself why you need to know about research methods when you could just Google the topic and find out all sorts of things about it. Here’s why—there is good research and bad research and everything else in between. The only way to tell the difference is by knowing what makes good research that results in trustworthy information.
Just as in any profession, gerontology has certain tools of the trade that are used to ensure good research.
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18 CHAPTER 1
what researchers think it measures. For example, a mea- sure of memory is valid only if it can be shown to actu- ally measure memory (and not vocabulary ability, for example). Validity often is established by showing that the measure in question is closely related to another measure known to be valid. Because it is possible to have a measure that is reliable but not valid (a ruler is a reliable measure of length but not a valid measure of memory), researchers must ensure that measures are both reliable and valid.
Systematic Observation. As the name implies, sys- tematic observation involves watching people and carefully recording what they say or do. Two forms of systematic observation are common. In naturalistic observation, people are observed as they behave spon- taneously in some real-life situation. For example, Leah and Sarah could be observed in the grocery store purchasing their items as a way to test how well they remember.
Structured observations differ from naturalistic observations in that the researcher creates a setting that is particularly likely to elicit the behavior of inter- est. Structured observations are especially useful for studying behaviors that are difficult to observe natu- rally. For example, how people react to emergencies is hard to study naturally because emergencies generally are rare and unpredictable events. A researcher could stage an emergency and watch how people react. How- ever, whether the behaviors observed in staged situ- ations are the same as would happen naturally often is hard to determine, making it difficult to generalize from staged settings to the real world.
Sampling Behavior with Tasks. When investiga- tors can’t observe a behavior directly, another popular alternative is to create tasks that are thought to sam- ple the behavior of interest. For example, one way to test older adults’ memory is to give them a grocery list to learn and remember. Likewise, police training includes putting the candidate in a building in which targets pop up that may be either criminals or innocent bystanders. This approach is popular with gerontologi- cal researchers because it is so convenient. The main question with this approach is its validity: Does the task provide a realistic sample of the behavior of inter- est? For example, asking people to learn grocery lists
would have good validity to the extent it matched the kinds of lists they actually use.
Self-Reports. The last approach, self-reports, is a special case of using tasks to sample people’s behavior. Self-reports are simply people’s answers to questions about the topic of interest. When questions are posed in written form, the verbal report is a questionnaire; when they are posed verbally, it is an interview. Either way, questions are created that probe different aspects of the topic of interest. For example, if you think imag- ery and lists are common ways people use to remem- ber grocery items, you could devise a questionnaire and survey several people to find out.
Although self-reports are very convenient and provide information on the topic of interest, they are not always good measures of people’s behavior, because they are inaccurate. Why? People may not remember accurately what they did in the past, or they may report what they think the researcher wants to hear.
Representative Sampling. Researchers usually are interested in broad groups of people called popula- tions. Examples of populations are all students taking a course on adult development and aging or all Asian American widows. Almost all studies include only a sample of people, which is a subset of the population. Researchers must be careful to ensure that their sample is truly representative of the population of interest. An unrepresentative sample can result in invalid research. For example, what would you think of a study of mid- dle-aged parents if you learned that the sample con- sisted entirely of two-parent households? You would, quite correctly, decide that this sample is not represen- tative of all middle-aged parents and question whether its results apply to single middle-aged parents.
As you read on, you’ll soon discover that most of the research we consider in this text has been con- ducted on middle-class, well-educated European Americans. Are these samples representative of all peo- ple in the United States? In the world? Sometimes, but not always. Be careful not to assume that findings from this group apply to people of other groups. In addition, some developmental issues have not been studied in all ethnic groups and cultures. For example, the U.S. government does not always report statistics for all ethnic groups. To change this, some U.S. government
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STUDYING ADULT DEVELOPMENT AND AGING 19
agencies, such as the National Institutes of Health, now require samples to be representative. Thus in the future we may gain a broader understanding of aging.
General Designs for Research Having selected the way we want to measure the topic of interest, researchers must embed this measure in a research design that yields useful, relevant results. Gerontologists rely on primary designs in planning their work: experimental studies, correlational stud- ies, and case studies. The specific design chosen for research depends in large part on the questions the researchers are trying to address.
Experimental Design. To find out whether Leah’s or Sarah’s approach to remembering works better, we could gather groups of older adults and try the follow- ing. We could randomly assign the participants into three groups: those who are taught to use imagery, those who are taught to use lists, and those who are not taught to use anything. After giving all the groups time to learn the new technique (where appropriate), we could test each group on a new grocery list to see who does better.
What we have done is an example of an experi- ment , which involves manipulating a key factor that the researcher believes is responsible for a particular behavior and randomly assigning participants to the experimental and control groups. In our case, the key variable being manipulated (termed the independent variable ) is the instructions for how to study. In a study of memory, a typical behavior that is observed (termed the dependent variable ) is the amount of information actually remembered.
More generally, in an experiment the researcher is most interested in identifying differences between groups of people. One group, the experimental group, receives the manipulation; another group, the control group, does not. This sets up a situation in which the level of the key variable of interest differs across groups. In addition, the investigator exerts precise control over all important aspects of the study, including the variable of interest, the setting, and the participants. Because the key variable is systematically manipulated in an experiment, researchers can infer cause-and- effect relations about that variable. In our example, we can conclude that type of instruction (how people
study) causes better or worse performance on a mem- ory test. Discovering such cause-and-effect relations is important if we are to understand the underlying pro- cesses of adult development and aging.
Finally, we must note that age cannot be an inde- pendent variable, because we cannot manipulate it. Consequently, we cannot conduct true experiments to examine the effects of age on a particular person’s behavior. At best, we can find age-related effects of an independent variable on dependent variables.
Correlational Design. In a correlational study , inves- tigators examine relations between variables as they exist naturally in the world. In the simplest correlational study, a researcher measures two variables, and then sees how they are related. Suppose we wanted to know whether the amount of time spent studying a grocery list such as one that Sarah might create was related to how many items people remember at the store. To find out, the researcher would measure two things for each person in the study: the length of study time and the number of items purchased correctly.
The results of a correlational study usually are measured by computing a correlation coefficient, abbreviated r . Correlations can range from – 1.0 to 1.0 , reflecting three different types of relations between study time and number of groceries remembered.
1. When r = 0 , the two variables are unrelated: Study time has no relation to remembering groceries.
2. When r > 0 , the variables are positively related: As study time increases (or decreases), the number of grocery items remembered also increases (or decreases).
3. When r < 0 , the variables are inversely related: When study time increases (or decreases), the number of groceries remembered decreases (or increases).
Correlational studies do not give definitive informa- tion about cause-and-effect relations; for example, the correlation between study time and the number of groceries remembered does not mean that one variable caused the other, regardless of how large the relation was. However, correlational studies do provide impor- tant information about the strength of the relation between variables, which is reflected in the absolute
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20 CHAPTER 1
value of the correlation coefficient. Moreover, because developmental researchers are interested in how vari- ables are related to factors that are very difficult, if not impossible, to manipulate, correlational techniques are used a great deal. In fact, most developmental research is correlational at some level because age cannot be manipulated within an individual. This means we can describe a great many developmental phenomena, but we cannot explain very many of them.
Case Studies. Sometimes researchers cannot obtain measures directly from people and are able only to watch them carefully. In certain situations, researchers may be able to study a single individual in great detail in a case study . This technique is especially useful when researchers want to investigate very rare phenomena, such as uncommon diseases or people with extremely high ability. Identifying new diseases, for example, begins with a case study of one individual who has a pattern of symptoms that is different from any known syndrome. Case studies are also very valuable for open- ing new areas of study, which can be followed by larger studies using other methods (e.g., experiments). How- ever, their primary limitation is figuring out whether the information gleaned from one individual holds for others as well.
Designs for Studying Development Once the general design is chosen, most gerontologists must decide how to measure possible changes or age differences that emerge as people develop. For example, if we want to know how people continue (or fail) to use imagery or lists in remembering grocery items as they get older, we will want to use a design that is particularly sensitive to developmental differences. Such designs are based on three key variables: age, cohort, and time of measurement. Once we have considered these, we will examine the specific designs for studying development.
Age, Cohort, and Time of Measurement. Every study of adult development and aging is built on the combina- tion of three building blocks: age, cohort, and time of measurement (Cavanaugh & Whitbourne, 2003).
Age effects reflect differences caused by underlying processes, such as biological, psychological, or sociocul- tural changes. Although usually represented in research by chronological age, age effects are inherent changes
within the person and are not caused by the passage of time per se.
Cohort effects are differences caused by experiences and circumstances unique to the generation to which one belongs. In general, cohort effects correspond to the normative history-graded influences discussed earlier. However, defining a cohort may not be easy. Cohorts can be specific, as in all people born in one particu- lar year, or general, such as the baby-boom cohort. As described earlier, each generation is exposed to dif- ferent sets of historical and personal events (such as World War II, tablet computers, or opportunities to attend college). Later in this section we consider evi- dence of how profound cohort effects can be.
Time-of-measurement effects reflect differences stemming from sociocultural, environmental, historical, or other events at the time the data are obtained from the participants. For example, data about wage increases given in a particular year may be influenced by the economic conditions of that year. If the economy is in a serious recession, pay increases probably would be small. In contrast, if the economy is booming, pay increases could be large. Clearly, whether a study is conducted during a recession or a boom affects what is learned about pay changes. In short, the point in time in which a researcher decides to do research could lead him or her to different conclusions about the phenom- enon being studied.
The three building-block variables (age, cohort, and time of measurement) can be represented in a sin- gle chart, such as the one shown in Table 1.1 . Cohort is represented by the years in the first column, time of measurement is represented by the years across the top, and age is represented by the numbers in the
Cohort is represented by the years in the first column, time of measure- ment by the years across the top, and age by the values in the cells.
Table 1.1
Three basic building blocks of developmental research TIME OF MEASUREMENT
Cohort 2000 2010 2020 2030
1950 50 60 70 80
1960 40 50 60 70
1970 30 40 50 60
1980 20 30 40 50
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STUDYING ADULT DEVELOPMENT AND AGING 21
individual cells. Note that age is computed by subtract- ing the cohort year from the time of measurement.
In conducting adult development and aging research, investigators have attempted to identify and separate the three effects. This has not been easy, because all three influences are interrelated. If one is interested in studying 40 - year - olds , one must neces- sarily select the cohort that was born 40 years ago. In this case age and cohort are confounded, because one cannot know whether the behaviors observed occur because the participants are 40 years old or because of the specific life experiences they have had as a result of being born in a particular histori- cal period. In general, confounding is any situation in which one cannot determine which of two or more effects is responsible for the behaviors being observed. Confounding of the three effects we are considering here is the most serious problem in adult develop- ment and aging research.
What distinguishes developmental researchers from their colleagues in other areas of psychology is a fundamental interest in understanding how people change. Developmental researchers must look at the ways in which people differ across time. Doing so necessarily requires that researchers understand the distinction between age change and age difference. An age change occurs in an individual’s behavior over time. Leah’s or Sarah’s memory at age 75 may not be as good as it was at age 40 . To discover an age change, one must examine the same person (in this case, Leah or Sarah) at more than one point in time. An age dif- ference is obtained when at least two different people of different ages are compared. Leah and Sarah may not remember as many grocery items as a person of age 40 . Even though we may be able to document sub- stantial age differences, we cannot assume they imply an age change. We do not know whether Leah or Sarah has changed since she was 40 , and of course we do not know whether the 40 - year-old will be any differ- ent at age 75 . In some cases age differences reflect age changes, and in some cases they do not.
If what we really want to understand in develop- mental research is age change (what happens as people grow older), we should design our research with this goal in mind. Moreover, different research questions necessitate different research designs. We next consider the most common ways in which researchers gather
Cross-sectional research has several weaknesses. Because people are tested at only one point in their devel- opment, we learn nothing about the continuity of devel- opment. Consequently, we cannot tell whether someone who remembers grocery items well at age 50 (in 2000) is still able to do so at age 80 (in 2030), because the person would be tested at age 50 or 80 , but not both. Cross- sectional studies also are affected by cohort effects, meaning that differences between age groups (cohorts) may result as easily from environmental events as from developmental processes. Why? Cross-sectional studies assume that when the older participants were younger, they resembled the people in the younger age groups in the study. This isn’t always true, of course, which makes it difficult to know why age differences are found in a cross-sectional study. In short, age and cohort effects are confounded in cross-sectional research.
Despite the confounding of age and cohort and the limitation of being able to identify only age differ- ences, cross-sectional designs dominate the research literature in gerontology. Why? The reason is a prag- matic one: Because all the measurements are obtained at one time, cross-sectional research can be conducted more quickly and inexpensively than research using other designs. In addition, one particular variation of
Cohort is represented by the years in the first column, time of measure- ment by the years across the top, and age by the values in the cells.
Table 1.2
Cross-sectional design TIME OF MEASUREMENT
Cohort 2000 2010 2020 2030
1950 50 60 70 80
1960 40 50 60 70
1970 30 40 50 60
1980 20 30 40 50
data about age differences and age changes: cross- sectional, longitudinal, time lag, and sequential designs.
Cross-Sectional Designs. In a cross-sectional study , developmental differences are identified by testing people of different ages at the same time. Any single column in Table 1.2 represents a cross-sectional design. Cross- sectional designs allow researchers to examine age dif- ferences but not age change.
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22 CHAPTER 1
cross-sectional designs is used the most: the extreme age groups design.
Suppose you want to investigate whether people’s ability to remember items at the grocery store differs with age. Your first impulse may be to gather a group of younger adults and compare their performance with that of a group of older adults. Typically, such studies compare samples obtained in convenient ways; younger adults usually are college students, and older adults often are volunteers from senior centers or church groups.
Although the extreme age groups design is very common (most of the studies cited in this book used this design), it has several problems (Hertzog & Dixon, 1996). Three concerns are key. First, the samples are not representative, so we must be very careful not to read too much into the results; findings from studies on extreme age groups may not generalize to people other than ones like those who participated. Second, age should be treated as a continuous variable, not as a category (“young” and “old”). Viewing age as a con- tinuous variable allows researchers to gain a better understanding of how age relates to any observed age differences. Finally, extreme age group designs assume the measures used mean the same thing across both age groups. Measures may tap somewhat different con- structs, so the reliability and validity of each measure should be checked in each age group.
Despite the problems with cross-sectional designs in general and with extreme age groups designs in par- ticular, they can provide useful information if used carefully. Most importantly, they can point out issues that may provide fruitful avenues for subsequent lon- gitudinal or sequential studies, in which case we can uncover information about age changes.
Longitudinal Designs. In a longitudinal study , the same individuals are observed or tested repeatedly at different points in their lives. As the name implies, a longitudinal study involves a lengthwise account of development and is the most direct way to watch growth occur. A longitudinal design is represented by any hori- zontal row in Table 1.3 . A major advantage of longitudi- nal designs is that age changes are identified because we are studying the same people over time.
Usually the repeated testing of longitudinal studies extends over years, but not always. In a microgenetic study , a special type of longitudinal design, participants
are tested repeatedly over a span of days or weeks, typically with the aim of observing change directly as it occurs. For example, researchers might test children every week, starting when they are 12 months old and continuing until 18 months. Microgenetic studies are particularly useful when investigators have hypotheses about a spe- cific period when developmental change should occur (Flynn, Pine, & Lewis, 2006), or in order to intensively document a behavior over time (e.g., Boom, 2012).
Microgenetic studies are particularly useful in tracking change as a result of intervention. For exam- ple, older adults could be given a series of measures of memory ability and then be interviewed about their use of memory strategies. A series of training sessions about how to improve memory could be introduced including additional memory tests and interviews, followed by a posttest to find out how well the par- ticipants learned the skills in which they were trained. The microgenetic method would look in detail at the performance of those who learned and improved after training, compared to those who did not, and search for differences in either the pattern of performance in the memory tests or in the details in the interviews for reasons why some people improved while others did not. This would provide a vivid portrait of change over the period of the intervention.
If age changes are found in longitudinal studies, can we say why they occurred? Because only one cohort is studied, cohort effects are eliminated as an explanation of change. However, the other two potential explana- tions, age and time of measurement, are confounded. For example, suppose we wanted to follow the 1990 cohort over time. If we wanted to test these individuals when they were 20 years old, we would have had to do
Cohort is represented by the years in the first column, time of measure- ment by the years across the top, and age by the values in the cells.
Table 1.3
Longitudinal Design TIME OF MEASUREMENT
Cohort 2000 2010 2020 2030
1950 50 60 70 80
1960 40 50 60 70
1970 30 40 50 60
1980 20 30 40 50
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STUDYING ADULT DEVELOPMENT AND AGING 23
so in 2010. Consequently, any changes we identify could result from changes in underlying processes or factors related to the time we choose to conduct our measure- ment. For instance, if we conducted a longitudinal study of salary growth, the amount of salary change in any comparison could stem from real change in the skills and worth of the person to the company or from the eco- nomic conditions of the times. In a longitudinal study we cannot tell which of these factors is more important.
Longitudinal studies have three additional poten- tial problems. First, if the research measure requires some type of performance by the participants, we may have the problem of practice effects. Practice effects result from the fact that performance may improve over time simply because people are tested over and over again with the same measures. Second, we may have a problem with participant dropout because it is difficult to keep a group of research participants intact over the course of a longitudinal study. Participants may move, lose interest, or die. Participant dropout can result in two different outcomes. We can end up with positive selective survival if the participants at the end of the study tend to be the ones who were initially higher on some variable (e.g., the surviving participants are the ones who were the most healthy at the beginning of the study). In contrast, we could have negative selec- tive survival if the participants at the conclusion of the study were initially lower on an important variable (e.g., the surviving participants may have been those who were initially less healthy).
The third problem with longitudinal designs is that our ability to apply the results to other groups is limited. The difficulty is that only one cohort is fol- lowed. Whether the pattern of results that is observed in one cohort can be generalized to another cohort is questionable. Thus researchers using longitudinal designs run the risk of uncovering a developmental process that is unique to that cohort.
Because longitudinal designs necessarily take more time and usually are expensive, they have not been used very often. However, researchers now recognize that we badly need to follow individuals over time to further our understanding of the aging process. Thus, longitudinal studies are becoming more common.
Sequential Designs. Thus far, we have considered two developmental designs, each of which has problems
Sequential designs represent different combina- tions of cross-sectional or longitudinal studies. In the table, a cross-sequential design consists of two or more cross-sectional studies conducted at two or more times of measurement. These multiple cross-sectional designs include the same age ranges; however, the participants are different in each wave of testing. For example, we might compare performances on intelli- gence tests for people between ages 20 and 50 in 1980 and then repeat the study in 1990 with a different group of people aged 30 to 60 .
Table 1.4 also depicts the longitudinal sequential design. A longitudinal sequential design consists of two or more longitudinal designs that represent two or more cohorts. Each longitudinal design in the sequence begins with the same age range and follows people for the same length of time. For example, we may want to begin a longitudinal study of intellectual development with a group of 50 - year-olds in 1980, using the 1930 cohort. We would then follow this cohort for a period of years. In 1990, we would begin a second longitudi- nal study on 50 - year-olds, using the 1940 cohort, and follow them for the same length of time as we follow
Cohort is represented by the years in the first column, time of measure- ment by the years across the top, and age by the values in the cells.
Table 1.4
Sequential Design TIME OF MEASUREMENT
Cohort 2000 2010 2020 2030
1950 50 60 70 80
1960 40 50 60 70
1970 30 40 50 60
1980 20 30 40 50
involving the confounding of two effects. These effects are age and cohort in cross-sectional designs, and age and time of measurement in longitudinal designs. These confounds create difficulties in interpreting behavioral differences between and within individuals, as illustrated in the How Do We Know? feature. Some of these interpretive dilemmas can be alleviated by using more complex designs called sequential designs, which are shown in Table 1.4 . Keep in mind, though, that sequential designs do not cure the confounding problems in the three basic designs.
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24 CHAPTER 1
HOW DO WE KNOW?: CONFLICTS BETWEEN CROSS-SECTIONAL AND LONGITUDINAL DATA Who was the investigator, and what was the aim of the study? In the 1950s, little information was available concerning longitudinal changes in adults’ intellectual abilities. What there was showed a developmental pat- tern of relative stability or slight decline, quite different from the picture of substantial across-the-board decline obtained in cross-sectional studies. To provide a more thorough picture of intellectual change, K. Warner Schaie began the Seattle Longitudinal Study in 1956.
How did the investigator measure the topic of interest? Schaie used standardized tests of primary mental abilities to assess a wide range of abilities such as logical reasoning and spatial ability.
Who were the participants in the study? Over the course of the study, more than 5,000 individuals have been tested at eight testing cycles (1956, 1963, 1970, 1977, 1984, 1991, 1998, and 2005). The participants were representative of the upper 75 % of the socio- economic spectrum and were recruited through a very large health maintenance organization in Seattle. Extensions of the study include longitudinal data on second-generation family members and on the grand- children of some of the original participants.
What was the design of the study? To provide a thorough view of intellectual change over time, Schaie invented a new type of design—the sequential design.
Participants were tested every seven years. Like most longitudinal studies, Schaie’s sequential study encoun- tered selectivity effects—that is, people who return over the years for retesting tend to do better initially than those who fail to return (in other words, those who don’t perform well initially tend to drop out of the study). However, an advantage of Schaie’s sequential design is that by bringing in new groups of participants, he was able to estimate the importance of selection effects, a major improvement over previous research.
Were there ethical concerns with the study? The most serious issue in any study in which participants are followed over time is confidentiality. Because peo- ple’s names must be retained for future contact, the researchers were very careful about keeping personal information secure.
What were the results? Among the many impor- tant findings from the study are differential changes in abilities over time and cohort effects. As you can see in Figure 1.9 , scores on tests of primary mental abili- ties improve gradually until the late 30 s or early 40 s . Small declines begin in the 50 s , increase as people age into their 60 s , and become increasingly large in the 70 s (Schaie & Zanjani, 2006).
Cohort differences were also found. Figure 1.10 shows that on some skills, such as inductive reasoning ability, but not others, more recently born younger and middle-aged cohorts performed better than cohorts born earlier. An example of the latter is that older cohorts outperformed younger ones on number skills (Schaie & Zanjani, 2006). These cohort effects probably
Figure 1.9 Longitudinal Changes in Intellectual Functions from Age 25 to 88 . Source : From “Intellectual Development Across Adulthood” by K. Warner Schaie and Faika A. K. Zanjani, in Handbook of Adult Development and Learning , ed. by C. Hoare, p. 102. Copyright © 2006 by Oxford University Press.
60
55
50
45
40
35
25 32 39 46 53 60 67 74 81 88 Age (years)
M ea
n T-
Sc o
re s
Word fluency
Number
Inductive reasoning
Spatial orientation
Verbal meaning
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STUDYING ADULT DEVELOPMENT AND AGING 25
reflect differences in educational experiences; younger groups’ education emphasized figuring things out on one’s own, whereas older groups’ education empha- sized rote learning. Additionally, older groups did not have calculators or computers, so they had to do math- ematical problems by hand.
Schaie uncovered many individual differences as well; some people showed developmental patterns closely approximating the overall trends, but others showed unusual patterns. For example, some individu- als showed steady declines in most abilities beginning in their 40 s and 50 s , others showed declines in some abilities but not others, but some people showed little change in most abilities over a 14 - year period. Such individual variation in developmental patterns means that average trends, like those depicted in the figures, must be interpreted cautiously; they reflect group aver- ages and do not represent the patterns shown by each person in the group.
Another key finding is that how intellectual abili- ties are organized in people does not change over time (Schaie et al., 1998). This finding is important because it means that the tests, which presuppose a particular organizational structure of intellectual abilities, can be used across different ages. Additionally, Schaie (1994) identified several variables that appear to reduce the risk of cognitive decline in old age:
Absence of cardiovascular and other chronic diseases
Living in favorable environmental conditions (such as good housing)
Remaining cognitively active through reading and lifelong learning
Having a flexible personality style in middle age Being married to a person with high cognitive
status Being satisfied with one’s life achievements in
middle age
What did the investigator conclude? Three points are clear. First, intellectual development during adult- hood is marked by a gradual leveling off of gains, followed by a period of relative stability, and then a time of gradual decline in most abilities. Second, these trends vary from one cohort to another. Third, individual patterns of change vary considerably from person to person.
Overall, Schaie’s findings indicate that intellectual development in adulthood is influenced by a wide vari- ety of health, environmental, personality, and relation- ship factors. By attending to these influences throughout adulthood, we can at least stack the deck in favor of maintaining good intellectual functioning in late life.
What converging evidence would strengthen these conclusions? Although Schaie’s study is one of the most comprehensive ever conducted, it is limited. Studying people who live in different locations around the world would provide evidence as to whether the results are limited geographically. Additional cross-cultural evi- dence comparing people with different economic back- grounds and differing access to health care would also provide insight into the effects of these variables on intellectual development.
Figure 1.10 Cohort differences in intellectual functions from birth cohorts between 1889 and 1973. Source : From “Intellectual Develop- ment Across Adulthood” by K. Warner Schaie and Faika A. K. Zanjani, in Handbook of Adult Development and Learning , ed. by C. Hoare, p. 106. Copyright © 2006 by Oxford University Press.
15
10
5
0
–5
Cohort (year of birth)
C um
ul at
iv e
M ea
n T-
Sc o
re D
if fe
re nc
es
1889 19031896 1907 1910 1917 1924 1931 1938 1945 1952 1959 1966 1973
Word fluency Intellectual ability
Number
Inductive reasoning
Spatial orientation
Verbal meaning
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26 CHAPTER 1
the first cohort. This design helps clarify whether the longitudinal effects found in a single longitudinal study are cohort-specific or are more general findings.
Although sequential designs are powerful and provide by far the richest source of information about developmental issues, few researchers use them, because they are costly. Trying to follow many people over long periods of time, generating new samples, and conducting complex data analyses are expensive and time consuming. Clearly, this type of commitment to one project is not possible for most researchers.
Integrating Findings from Different Studies Several times in the past few pages, we’ve emphasized the value of using different methods to study the same phenomenon. The advantage of this approach is that conclusions are most convincing when the results are the same regardless of method.
In reality, though, findings are often inconsistent. Suppose, for example, many researchers find that peo- ple often share personal information with friends (e.g., through Facebook or Google+), some researchers find that people share occasionally with friends, and a few researchers find that people never share with friends. What results should we believe? What should we con- clude? Meta-analysis allows researchers to synthesize the results of many studies to estimate relations between variables (Plonsky & Oswald, 2012). In conducting a meta-analysis, investigators find all studies published on a topic over a substantial period of time (e.g., 10 to 20 years), and then record and analyze the results and important methodological variables.
Thus, meta-analysis is a particularly powerful tool because it allows scientists to determine whether a finding generalizes across many studies that used dif- ferent methods. In addition, meta-analysis can reveal the impact of those different methods on results.
Conducting Research Ethically Choosing a good research design involves more than just selecting a particular method. Researchers must determine whether the methods they plan on using are ethical. That is, when designing a research study, investigators must do so in a way that does not vio- late the rights of people who participate. To verify that every research project has these protections, local pan- els of experts and community representatives review
proposed studies before any data are collected. Only with the approval of this panel can scientists begin their study. If the review panel objects to some aspects of the proposed study, the researcher must revise those aspects and present them anew for the panel’s approval. Likewise, each time a component of a study is changed, the review panel must be informed and give its approval.
To guide review panels, professional organizations (e.g., the American Psychological Association) and government agencies (e.g., the National Institutes of Health) have codes of conduct that specify the rights of research participants and procedures to protect these participants. The following essential guidelines are included in all of these codes:
Minimize risks to research participants. Use meth- ods that have the least potential for causing harm or stress for research participants. During the research, monitor the procedures to be sure to avoid any unforeseen stress or harm.
Describe the research to potential participants so they can determine whether they wish to partici- pate. Prospective participants must be told the purpose of the project, what they will be asked to do, whether there are any risks or potential harm, any benefits they may receive, that they are free to discontinue participation at any time without pen- alty, that they are entitled to a complete debriefing at the end of the project, and any other relevant information the review panel deems appropriate. After the study has been explained, participants sign a document that says they understand what they will do in the study. Special caution must be exercised in obtaining consent for the participa- tion of children and adolescents, as well as people who have conditions that affect intellectual func- tioning (e.g., Alzheimer’s disease, severe head injury). In these cases, consent from a parent, legal guardian, or other responsible person, in addition to the agreement of the person him- or herself, is necessary for participation.
Avoid deception; if participants must be deceived, provide a thorough explanation of the true nature of the experiment as soon as possible. Providing complete information about a study in advance sometimes biases or distorts a person’s responses.
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STUDYING ADULT DEVELOPMENT AND AGING 27
Consequently, investigators may provide partici- pants with partial information about the study or even mislead them about its true purpose. As soon as it is feasible—typically just after the experiment—any false information that was given to research participants must be corrected, and the reasons for the deception must be provided.
Results should be anonymous or confidential. Research results should be anonymous, which means that people’s data cannot be linked to their name. When anonymity is not possible, research results should be confidential, which means the identity of participants is known only to the inves- tigator conducting the study. The requirement for informed consent is very
important. If prospective participants cannot complete the informed consent procedure themselves, perhaps because they are incapacitated or because they have a condition, such as Alzheimer’s disease, that causes intellectual impairment, special cautions must be taken. The American Geriatrics Society (1998) and the Alzheimer’s Association (2004), among other profes- sional organizations, have published guidelines outlin- ing some of these protections. For example, when the participant cannot understand the consent process, someone else (usually a family member) must com- plete it. In addition, the researcher must describe the procedures to the participant and still obtain the par- ticipant’s assent. However, this process is task specific; some cognitively impaired people, particularly early in the disease process, can respond appropriately to certain types of consent. And researchers can obtain advance consent for future participation when the cog- nitive impairment is more severe. In all cases, though, researchers must take extra precautions to be sensitive to these individuals; for example, if it becomes appar- ent that the participant does not like the procedures, the researcher must stop collecting data from that individual.
Social Policy Implications Creating sound social policy requires good informa- tion. Elected officials and others who create policy rely on research findings to provide the basis for pol- icy. In terms of social policies affecting older adults, the data obtained through the use of the research designs discussed earlier are critical.
For example, research such as Schaie’s research on intellectual development described in the How Do We Know? feature had a major impact on the elimination of nearly all mandatory retirement rules in the 1980s. Research on worker satisfaction and post-retirement lifestyles influenced decisions in cor- porations such as McDonald’s and Wal-Mart to hire older adults, who are highly reliable employees. The buying power of older adults has resulted in major advertising campaigns for everything from calcium replacement medications to active lifestyles.
In each of the remaining chapters, we will be highlighting a particular social policy and how it relates to research. By making these ties, you will be able to understand better how research findings can be applied to address social issues.
Adult Development in Action If you were responsible for making grants at your local United Way organization, how might you determine through research whether the programs you fund actually have the outcomes they claim?
These ethical principles provide important protec- tions for participants and investigators alike. By treat- ing research participants with respect, investigators are in a better position to make important discoveries about adult development and aging.
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28 CHAPTER 1
Summary 1.1 Perspectives on Adult Development and Aging
What is gerontology? How does ageism relate to stereotypes of aging?
Gerontology is the study of aging from maturity through old age, as well as the study of older adults as a special group.
Myths of aging lead to negative stereotypes of older people, which can result in ageism, a form of discrimination against older people simply because of their age.
What is the life-span perspective? The life-span perspective divides human develop-
ment into two phases: an early phase (childhood and adolescence) and a later phase (young adult- hood, middle age, and old age).
There are four key features of the life-span per- spective: multidirectionality, plasticity, historical context, and multiple causation.
What are the characteristics of the older adult population?
The number of older adults in the United States and other industrialized countries is increasing rapidly because of better health care, including declines in mortality during childbirth. The large numbers of older adults have important implica- tions for human services.
The number of older Latino, Asian American, and Native American adults will increase much faster between now and 2050 than will the number of European American and African American older adults.
Whether older adults reflect individualism or col- lectivism has implications for interventions.
The increase in numbers of older adults is most rapid in developing countries.
1.2 Issues in Studying Adult Development and Aging
What four main forces shape development? Development is shaped by four forces. (1) Biologi-
cal forces include all genetic and health-related factors. (2) Psychological forces include all inter- nal perceptual, cognitive, emotional, and per- sonality factors. (3) Sociocultural forces include interpersonal, societal, cultural, and ethnic factors.
(4) Life-cycle forces reflect differences in how the same event or combination of biological, psycho- logical, and sociocultural forces affects people at different points in their lives.
What are normative age-graded influences, normative history-graded influences, and nonnormative influences?
Normative age-graded influences are life experi- ences that are highly related to chronological age. Normative history-graded influences are events that most people in a specific culture experience at the same time. Nonnormative influences are events that may be important for a specific individual but are not experienced by most people.
How do culture and ethnicity influence aging? Culture and ethnicity jointly provide status, social
settings, living conditions, and personal experi- ences for people of all ages. Culture can be defined as shared basic value orientations, norms, beliefs, and customary habits and ways of living, and it pro- vides the basic worldview of a society. Ethnicity is an individual and collective sense of identity based on historical and cultural group membership and related behaviors and beliefs.
What is the meaning of age? Three types of aging are distinguished. (1) Primary
aging is normal, disease-free development during adulthood. (2) Secondary aging is developmental changes that are related to disease. (3) Tertiary aging is the rapid losses that occur shortly before death.
Chronological age is a poor descriptor of time- dependent processes and serves only as a shorthand for the passage of calendar time. Time-dependent processes do not actually cause behavior.
Perceived age is the age you think of yourself as being. Better definitions of age include biological age
(where a person is relative to the maximum num- ber of years he or she could live), psychological age (where a person is in terms of the abilities people use to adapt to changing environmental demands), and sociocultural age (where a person is in terms of the specific set of roles adopted in relation to other members of the society and culture).
What are the nature–nurture, stability–change, continuity–discontinuity, and the “universal versus context-specific development” issues?
The nature–nurture issue concerns the extent to which inborn, hereditary characteristics (nature)
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STUDYING ADULT DEVELOPMENT AND AGING 29
and experiential, or environmental, influences (nurture) determine who we are. The focus on nature and nurture must be on how they interact.
The stability–change issue concerns the degree to which people remain the same over time.
The continuity–discontinuity issue concerns com- peting views of how to describe change: as a smooth progression over time (continuity) or as a series of abrupt shifts (discontinuity).
The issue of universal versus context-specific devel- opment concerns whether there is only one path- way of development or several. This issue becomes especially important in interpreting cultural and ethnic group differences.
1.3 Research Methods
What approaches do scientists use to measure behavior in adult development and aging research?
Measures used in research must be reliable (mea- sure things consistently) and valid (measure what they are supposed to measure).
Systematic observation involves watching peo- ple and carefully recording what they say or do. Two forms are common: naturalistic observation (observing people behaving spontaneously in a real-world setting) and structured observations (creating a setting that will elicit the behavior of interest).
If behaviors are hard to observe directly, research- ers often create tasks that sample the behavior of interest.
Self-reports involve people’s answers to questions presented in a questionnaire or interview about a topic of interest.
Most research on adults has focused on middle- class, well-educated European Americans. This creates serious problems for understanding the development experiences of other groups of people.
What are the general designs for doing research?
Experiments consist of manipulating one or more independent variables, measuring one or more dependent variables, and randomly assigning par- ticipants to the experimental and control groups. Experiments provide information about cause and effect.
Correlational designs address relations between variables; they do not provide information about cause and effect but do provide information about the strength of the relation between the variables.
Case studies are systematic investigations of indi- vidual people that provide detailed descriptions of people’s behavior in everyday situations.
What specific designs are unique to adult development and aging research?
Age effects reflect underlying biological, psycho- logical, and sociocultural changes. Cohort effects are differences caused by experiences and cir- cumstances unique to the generation to which one belongs. Time-of-measurement effects reflect influences of the specific historical time when one is obtaining information. Developmental research designs represent various combinations of age, cohort, and time-of-measurement effects. Con- founding is any situation in which one cannot determine which of two or more effects is respon- sible for the behaviors being observed.
Cross-sectional designs examine multiple cohorts and age groups at a single point in time. They can identify only age differences and confound age and cohort. The use of extreme age groups (young and older adults) is problematic in that the samples may not be representative, age should be treated as a continuous variable, and the measures may not be equivalent across age groups.
Longitudinal designs examine one cohort over two or more times of measurement. They can identify age change but have several problems, including practice effects, dropout, and selective survival. Longitudinal designs confound age and time of measurement. Microgenetic studies are short-term longitudinal designs that measure behaviors very closely over relatively brief periods of time.
Sequential designs involve more than one cross-sec- tional (cross-sequential) or longitudinal (longitudi- nal sequential) design. Although they are complex and expensive, they are important because they help disentangle age, cohort, and time-of-mea- surement effects.
Meta-analyses examine the consistency of findings across many research studies.
What ethical procedures must researchers follow? Investigators must obtain informed consent from
their participants before conducting research.
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30 CHAPTER 1
Review Questions 1.1 Perspectives on Adult Development and Aging
What are the premises of the life-span perspective? How are population demographics changing around
the world, and what difference does it make?
1.2 Issues in Studying Adult Development and Aging What are the four basic forces in human devel-
opment? What are the major characteristics of normative
age-graded, normative history-graded, and non- normative influences?
How do nature and nurture interact? What are culture and ethnicity? In what ways can age be defined? What are the
advantages and disadvantages of each definition? What is the stability–change issue? What is the continuity–discontinuity issue? What
kinds of theories derive from each view? What is the universal versus context-specific devel-
opment issue, and how does it relate to sociocul- tural forces?
1.3 Research Methods What are the reliability and validity of a measure? What are the three main approaches scientists use
to measure behavior in adult development and aging research? What are the strengths and weak- nesses of each?
How do we know whether a sample is represen- tative?
What is an experiment? What information does it provide?
What is a correlational design? What information does it provide?
What is a case study? What information does it provide?
What are age, cohort, and time-of-measurement effects? How and why are they important for developmental research?
What is a cross-sectional design? What are its advantages and disadvantages?
What is a longitudinal design? What are its advan- tages and disadvantages?
What differences are there between cross-sectional and longitudinal designs in terms of uncovering age differences and age changes?
What are sequential designs? What different types are there? What are their advantages and disad- vantages?
What are the limitations of the extreme age groups design?
What steps must researchers take to protect the rights of participants?
INTEGRATING CONCEPTS IN DEVELOPMENT Analyze each of the four major controversies in
development in terms of the four developmental forces. What real-world examples can you think of that are examples of each combination of contro- versy and force?
Using yourself as an example, figure out your age using chronological, perceived, biological, psycho- logical, and sociocultural definitions. How do they differ? Why?
Using the Leah and Sarah vignette as an example, design cross-sectional, longitudinal, and sequential studies of two different styles of caring for people with Alzheimer’s disease. What will you learn from each of the studies?
KEY TERMS age effects One of the three fundamental effects examined in developmental research, along with cohort and time-of-measurement effects, which reflects the influence of time-dependent processes on development.
ageism The untrue assumption that chronological age is the main determinant of human characteristics and that one age is better than another.
biological forces One of four basic forces of devel- opment that includes all genetic and health-related factors.
biopsychosocial framework Way of organizing the biological, psychological, and sociocultural forces on human development.
case study An intensive investigation of individual people.
cohort A group of people born at the same point or specific time span in historical time.
cohort effects One of the three basic influences exam- ined in developmental research, along with age and time-of-measurement effects, which reflects differ- ences caused by experiences and circumstances unique to the historical time in which one lives.
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STUDYING ADULT DEVELOPMENT AND AGING 31
confounding Any situation in which one cannot deter- mine which of two or more effects is responsible for the behaviors being observed.
continuity–discontinuity controversy The debate over whether a particular developmental phenomenon represents smooth progression over time (continuity) or a series of abrupt shifts (discontinuity).
correlational study An investigation in which the strength of association between variables is examined.
cross-sectional study A developmental research design in which people of different ages and cohorts are observed at one time of measurement to obtain infor- mation about age differences.
dependent variable Behaviors or outcomes measured in an experiment.
emerging adulthood A period when individuals are not adolescents but are not yet fully adults.
experiment A study in which participants are ran- domly assigned to experimental and control groups and in which an independent variable is manipulated to observe its effects on a dependent variable so that cause-and-effect relations can be established.
gerontology The study of aging from maturity through old age.
independent variable The variable manipulated in an experiment.
life-cycle forces One of the four basic forces of devel- opment that reflects differences in how the same event or combination of biological, psychological, and sociocultural forces affects people at different points in their lives.
life-span perspective A view of the human life-span that divides it into two phases: childhood/adolescence and young/middle/late adulthood.
longitudinal study A developmental research design that measures one cohort over two or more times of measurement to examine age changes.
meta-analysis A technique that allows researchers to synthesize the results of many studies to estimate rela- tions between variables.
microgenetic study A special type of longitudinal design in which participants are tested repeatedly over a span of days or weeks, typically with the aim of observing change directly as it occurs.
nature–nurture issue A debate over the rela- tive influence of genetics and the environment on development.
nonnormative influences Random events that are important to an individual but do not happen to most people.
normative age-graded influences Experiences caused by biological, psychological, and sociocultural forces that are closely related to a person’s age.
normative history-graded influences Events that most people in a specific culture experience at the same time.
plasticity The belief that capacity is not fixed, but can be learned or improved with practice.
primary aging The normal, disease-free development during adulthood.
psychological forces One of the four basic forces of development that includes all internal perceptual, cognitive, emotional, and personality factors.
reliability The ability of a measure to produce the same value when used repeatedly to measure the identical phenomenon over time.
secondary aging Developmental changes that are related to disease, lifestyle, and other environmental changes that are not inevitable.
self-reports People’s answers to questions about a topic of interest.
sequential designs Types of developmental research designs involving combinations of cross-sectional and longitudinal designs.
sociocultural forces One of the four basic forces of development that include interpersonal, societal, cul- tural, and ethnic factors.
stability–change issue A debate over the degree to which people remain the same over time as opposed to being different.
systematic observation A type of measurement involv- ing watching people and carefully recording what they say or do.
tertiary aging Rapid losses occurring shortly before death.
time-of-measurement effects One of the three funda- mental effects examined in developmental research, along with age and cohort effects, which result from the time at which the data are collected.
universal versus context-specific development contro- versy A debate over whether there is a single pathway of development, or several.
validity The degree to which an instrument measures what it is supposed to measure.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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Neuroscience as a Basis for Adult
Development and Aging
2.1 THE NEUROSCIENCE APPROACH Neuroimaging Techniques • Neuroscience Perspectives • Discovering Development: What Do People Believe about Brain Fitness?
2.2 NEUROSCIENCE AND ADULT DEVELOPMENT AND AGING How Is the Brain Organized? • What Age-Related Changes Occur in Neurons? • What Age-Related Changes Occur in Neurotransmitter? • What Age-Related Changes Occur in Brain Structures? • What Do Structural Brain Changes Mean? • How Do We Know?: The Aging Emotional Brain
2.3 MAKING SENSE OF NEUROSCIENCE RESEARCH: EXPLAINING CHANGES IN BRAIN-BEHAVIOR RELATIONS The Parieto-Frontal Integration Theory • Can Older Adults Compensate for Changes in the Brain? • Theories of Brain-Behavior Changes Across Adulthood
2.4 NEURAL PLASTICITY AND THE AGING BRAIN Current Controversies: Are Neural Stem Cells the Solution to Brain Aging? • Exercise and Brain Aging • Nutrition and Brain Aging
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 2
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 33
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You see and hear more and more advertisements and literature touting the importance of “brain fitness.” In the grocery store and on television, marketers and self-help solicitors encourage people to eat the right “brain foods” filled with antioxidants. They promise that these antioxidants will protect your cells from the harmful effect of free radicals , substances that can damage cells, including brain cells, and play a role in cancer and other diseases as we grow older. Similarly, advertisements pro- mote exercising your brain through mental aero- bics such as playing chess, reading the newspaper, and attending plays. There is an entire industry of online and computerized brain-training games, such as Lumosity.com, aimed at delaying the onset of cognitive decline and prolonging cogni- tive vitality. This relatively recent phenomenon has coincided with the rapid surge of research in neuroscience or the study of the brain — in par- ticular, plasticity of the aging brain . Images such as the one shown below help us measure brain activity. Evidence that the brain can change for
the better as we grow older sends an intriguing message to our aging population. However, there is danger in this. As in any relatively new field, descriptions in the media, especially the Internet, may extend well beyond the actual scope of our scientific understanding of the brain.
In this chapter we explore our understanding of the aging brain by examining contemporary theories and recent empirical findings of neurosci- ence and aging. First, we briefly review the various neuroscience theories underlying and techniques used in studying the brain. Next, we focus on cognitive neuroscience and aging including age- related change in brain structures, neurochemical properties, and brain function. Two contemporary areas of research are explored, including cultural influences on brain aging, as well as neural plas- ticity in later adulthood. Finally, we explore more recent developments in the area of social neurosci- ence and aging—in particular, intriguing findings that reveal the neurological underpinnings of enhanced emotional processing in older adulthood in contrast to declines in cognitive processing such as the ability to control information in the con- scious mind.
Images such as this help us understand how the brain operates.
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34 CHAPTER 2
2.1 The Neuroscience Approach LEARNING OBJECTIVES
What brain imaging techniques are used in neuroscience research?
What are the main research methods used and issues studied in neuroscience research in adult development and aging?
At age 70 , Margaret was having trouble moving the left side of her body. With the aid of accurate brain imaging techniques, she was diagnosed as having a tumor located at the front of the right motor cortex. (Because the brain is wired in general to control the side of the body opposite of the side of the brain in question, movement on one’s left side is controlled by the right side of the brain in the area called the motor cortex.) With image-guided sur- gery, the tumor was removed, and Margaret recovered comfortably.
How did Margaret’s physicians figure out what was wrong with her? We are learning a great deal about the relations between changes in the brain and changes in behavior through technological advances in noninvasive imaging and in assessing psychological functioning (Blanchard-Fields, 2010; Linden, 2012). Neuroimaging is a set of techniques in which pictures of the brain are taken in various ways to provide under- standing of both normal and abnormal cognitive aging.
Neuroimaging Techniques What neuroimaging does is allow us to see inside the brain of a living person to examine the various struc- tures of the brain. Neuroimaging has revolutionized our understanding of the relations between the brain and our behavior, and it is responsible for an explosion of knowl- edge over the past few decades. Advances in neuroim- aging have led to much of our understanding of such diseases as Alzheimer’s disease (which we will consider in detail in Chapter 10 ) and to other key insights into age-related changes that occur to everyone and those changes that reflect disease or other abnormal changes.
But neuroimaging must be used carefully and ethically. For one thing, we are still figuring out which changes in the brain are normative and which ones are not. We need to know what a “healthy” brain looks like at different points in the human life span. So just because we observe a change does not mean anything
in and of itself unless additional research is done to place it in context.
Two neuroimaging techniques are used most often: 1. Structural neuroimaging provides highly detailed
images of anatomical features in the brain. The most commonly used are X-rays, computerized tomog- raphy (CT) scans, and magnetic resonance imag- ing (MRI). Images from structural neuroimaging techniques are like photographs in that they docu- ment what a specific brain structure looks like at a specific point in time. Structural neuroimaging is usually effective at identifying such things as bone fractures, tumors, and other conditions that cause structural damage in the brain, such as strokes.
2. Functional neuroimaging provides an indication of brain activity but not high anatomical detail. The most commonly used neuroimaging techniques are single photon emission computerized tomography (SPECT), positron emission tomography (PET), functional magnetic resonance imaging (fMRI), magnetoencephalograpy (or multichannel encepha- lography), and near infrared spectroscopic imaging (NIRSI). In general, fMRI is the most commonly used technique in cognitive neuroscience research (Poldrack, 2012). Functional neuroimaging pro- vides researchers with information about what parts of the brain are active when people are doing spe- cific tasks. A typical image will show different lev- els of brain activity as different colors; for example, red on an image might indicate high levels of brain activity in that region, whereas blue might indicate low levels of activity. These techniques, coupled with tests of behav-
ior such as specific cognitive processing tasks (e.g., recognizing which pictures you studied from a deck containing pictures you saw and pictures you did not), have shown quite convincingly that age-related brain changes are responsible for age-related changes in per- formance (Blanchard-Fields, 2010; Guidotti Breting, Tuminello, & Han, 2012).
In Margaret’s case, a magnetic resonance imaging (MRI) scan was conducted. This identified areas of the brain associated with specific functions. The scan pro- duced an image showing the brain location of inter- est and the outline of a tumor in the area of the brain involved in controlling movement.
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 35
In addition to using MRIs to locate brain tumors, we are interested in how neuroimaging techniques advance our understanding of how the brain changes as we grow older. Do the changes reflect decline, sta- bility, or perhaps improvement and compensation? Is there plasticity or growth in the aging brain? These are important questions that researchers in the field of contemporary neuroscience and aging are exploring.
A neuroscientific approach to the study of aging has several advantages. For example, the neurosci- ence approach has resulted in the development of new, effective interventions that are enhancing the quality of life of older adults and that can be evaluated not only by observing behavioral change but also at the neuro- logical level, such as the relationship between physical activity and cognitive aging (e.g., Jak, 2012).
These techniques and others can test models of cognitive aging. Neuroscience has become increas- ingly more relevant to cognitive aging research as the focus has expanded beyond studying pathologies of the
aging brain, such as Alzheimer’s or Parkinson’s disease, toward investigating normative and healthy aging. In addition, neuroscientific data are more informative for models of cognitive aging and usher in increased prog- ress in the field by testing established theories using cutting-edge methods. Furthermore, examination of the structure and function of the brain has become even more informative for cognitive aging research as the focus has shifted from describing brain activation patterns toward explaining them.
Neuroscience Perspectives Researchers take three general methodological per- spectives in tackling the neuroscience of aging: the neuropsychological, the neurocorrelational, and the activation imaging approach (see Cabeza, 2004). The neuropsychological approach compares brain functioning of healthy older adults with adults displaying various pathological disorders in the brain. In this approach researchers are interested in whether patients of any age with damage in specific regions of the brain show similar cognitive deficits to those shown by healthy older adults. If this is the case, then researchers can conclude that decline in cognitive functioning as we grow older may be related to unfavorable changes in the same specific regions of the brain observed in the brain-damaged patients.
Let’s suppose this type of comparison is made between healthy older adults and persons showing frontal lobe damage. People with brain damage in the frontal lobe display lower levels of dopamine (a chemi- cal substance we will consider a bit later in detail), which results in a decrease in how quickly mental pro- cessing occurs, termed speed of processing. Interest- ingly, this same slowing resembles what is observed in healthy older adults.
Another important objective of research using this approach is to isolate the neural or brain mechanisms that are associated with both normal and pathological decline in cognitive functions. These findings stimulate development of theories by identifying influential fac- tors that warrant theoretical explanation as to how and why these factors may cause cognitive decline as we age.
Just as we saw in Chapter 1 in relation to adult development and aging research in general, neurosci- ence researchers use certain research designs to study changes in brain structures and processes.
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36 CHAPTER 2
The neurocorrelational approach attempts to relate measures of cognitive performance to measures of brain structure or functioning. For example, a researcher may be interested in the correlation between cognitive behavior, such as the ability to remember informa- tion over short periods of time, and neural structural measures, such as the volume of the brain or activity in specific areas of the brain (Cabeza & Dennis, 2013). Instead of direct measures of brain structure or func- tioning, some researchers investigate the correlation between behavioral tests that are associated with the function of specific brain regions (e.g., tests of frontal lobe functioning). However, this approach is specu- lative, in that we cannot be certain whether the tests accurately reflect the actual anatomical and functional activity of the specific brain region under investigation.
The activation imaging approach attempts to directly link functional brain activity with cognitive behav- ioral data. This approach allows real-time investigation of changes in brain function as they affect cognitive per- formance in older adults. As you may have surmised, this approach relies on functional neuroimaging techniques, such as fMRI. For example, studies using this approach have found that younger adults’ brains show unilateral activation (i.e., activation in only one hemisphere of the brain) when they perform specific cognitive tasks, but older adults’ brains tend to show increased activation in both brain hemispheres when performing the same tasks (see Cabeza, 2002; Grady, 2012). As we will discuss later, this difference in activation in younger and older adult brains may provide neurological evidence that older adults’ brains compensate for age-related changes. Compensatory changes are changes that allow older adults to adapt to the inevitable behavioral decline result- ing from changes in specific areas of the brain.
Overall, neuroscience has brought an important perspective to studying cognitive aging, influencing theories of adulthood in several ways. First, theories of brain-behavior relations can be tested using these approaches. For instance, age-related changes in how we selectively direct our attention to specific character- istics of our environment can be validated by examining how age-related changes in performance are associated with both functional and structural changes in the brain. In other words, we can explain how changes in performance map to changes in the brain.
Second, research methods that focus on the age- related changes in the structure and functioning of the
brain can help to explain why certain cognitive func- tions, such as well-practiced tasks, vocabulary, and wisdom, can be preserved into old age while other functions, such as processing speed, decline rapidly as people age. By carefully tracking which brain struc- tures and functions change in which direction—or in some cases remain the same—we can differentiate and explain seemingly contradictory patterns of behavior over time.
Neuroscientific methods, however, have limita- tions (Alam, Patel, & Giordano, 2012). Like any set of tools, neuroscience techniques must be used appro- priately and ethically. Nevertheless, advances in the field of neuroscience have had a major impact on our understanding of cognitive aging because they have revealed new findings that psychological theories have to account for and be consistent with.
Before we explore some of the scientific research on age-related changes in the brain, complete the Discovering Development exercise. Compare your findings with the evidence described in the text that follows. What similarities and differences are revealed?
DISCOVERING DEVELOPMENT: WHAT DO PEOPLE BELIEVE ABOUT BRAIN FITNESS? With all the hype about keeping your brain fit, what do people believe you have to do to accomplish this? To find out, ask some people of different ages these questions:
What happens to the brain as we grow older? What do you think causes these changes? What do you think you can do to make sure
that the brain stays fit as you grow older?
Compile the results from your interviews and com- pare them with what you discover in this chapter. To what extent do people’s beliefs correspond to the sci- entific evidence? In which areas are they completely off base?
Adult Development in Action How would a physician decide whether to use structural neuroimaging or functional neuroimaging to aid in a clinical diagnosis?
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 37
2.2 Neuroscience and Adult Development and Aging LEARNING OBJECTIVES
How is the brain organized structurally? What are the basic changes in neurons as we age? What changes occur in neurotransmitters with
age? What changes occur in brain structures with age? What do age-related structural brain changes
mean for behavior?
Samuel is 73 , and he is worried about contracting Alzheimer’s disease. He remembers that his father became disoriented at this age and had trouble remem- bering things that he had just been told. How can Samuel find out if his brain is aging normally or pathologically? Psychological tests are somewhat predictive of disease— but not completely. This is a dilemma older adults are facing in our society today.
Much adult development and aging research has focused on cognitive aging, both normal and pathological. Historically, this research was based on behavioral data, which in turn gave rise to the clas- sic theories of cognitive aging (see Chapter 6 ; Salt- house, 1996; Schaie, 1996). More recently, though, the availability of neuroscientific methods has stimu- lated research that allows us to study cognitive pro- cesses—and changes in these processes—in the living brain, using noninvasive brain imaging techniques discussed earlier. For instance, brain activity involved in the identification of faces occurs in areas of the brain that are among the first affected by Alzheimer’s
disease (Saavedra, Iglesias, & Olivares, 2012). And so changes in brain activity in these regions may signal the onset of the disease before other, more apparent changes, occur.
This is exactly the type of information in which Samuel, the man in the vignette, would be interested. To make these types of discoveries, we must first have a strong knowledge base of how the brain ages nor- mally. Let’s examine what the field of neuroscience and aging has contributed to our knowledge of the aging brain.
How Is the Brain Organized? The human brain is an amazingly complex organ. It still remains more flexible and capable than any com- puter, handling billions of computations and provid- ing us with the wide range of emotions we experience. Needless to say, the structure of such a complex organ is, well, complex. At the most basic level, the brain is made up of cells called neurons , an example of which is shown in Figure 2.1 . Key structural features of the neuron are the dendrites , which act like antennas to receive signals from other nearby neurons, the axon , which is part of the neuron containing the neurofibers , which are the structures that carry information inside the neuron from the dendrites to the terminal branches , which are the endpoints of the neuron . Neurons do not physically touch each other. In order for information to be passed from one neuron to another, the terminal branches release chemicals called neurotransmitters , that travel across the space between neurons, called the synapse , where they are received by the dendrites of the next neuron .
Cell body
Dendrites
Terminal buttons
Direction of information flow
Axon
Figure 2.1 A typical neuron showing dendrites, axon, neurofibers, and terminal branches. © 2015 Cengage Learning
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38 CHAPTER 2
Now that we know the basic building block of the brain, let’s take a look at how the neurons themselves are organized into various brain structures. Figure 2.2 shows the major structures of the brain that are the focus of neuroscience research in adult development and aging. The study of the structure of the brain, called , neuroanatomy , is fundamental to neuroscience . We will refer to a number of brain regions that exhibit age- related changes in both structure and function.
The cerebral cortex is the outermost part of the brain. It consists of two hemispheres (left and right) that are connected by a thick bundle of neurons called the corpus callosum . Most neuroscience research focuses on the cerebral cortex.
Each region of the brain has distinguishing fea- tures that relate to the specific functions those regions control. For example, in most people, language pro- cessing is associated primarily with the left hemi- sphere, whereas recognizing nonspeech sounds, emotions, and faces is associated with the right hemi- sphere. The prefrontal and frontal cortex is intimately involved in higher-order executive functions such as the ability to make and carry out plans, switch between tasks, and maintain attention and focus, and connects
with other key brain structures that are involved with emotion. In addition, the cerebellum , at the back of the brain, controls equilibrium and the coordination of fine motor movements, and may be involved in some cognitive functions. The hippocampus , located in the middle of the brain, is a key structure associated with memory. The limbic system is a set of brain structures involved with emotion, motivation, and long-term memory, among other functions. For adult develop- ment and aging research, the most important compo- nents of the limbic system include the amygdala , and the hippocampus.
Details regarding both additional brain structures and the functional aspects of the various regions of the brain will be discussed more fully with respect to spe- cific age-related changes.
What Age-Related Changes Occur in Neurons?
Several changes occur with age in neurons (Juraska & Lowery, 2012). As we age, the number of neurons in the brain declines. Structural changes include decreases in the size and number of dendrites, the development of tangles in the fibers that make up the
Cerebral cortex
Corpus callosum
Prefrontal and frontal cortex
Cerebellum
Hippocampus
Amygdala
Limbic system Figure 2.2 Major structures of the human brain showing cerebral cortex, corpus callosum, prefrontal and frontal cortex, cerebellum hippocampus, limbic system, and amygdala. © 2015 Cengage Learning
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 39
axon, and increases in the deposit of certain proteins. The number of potential connections also declines, as measured by the number of synapses among neurons.
Interestingly, these same changes occur but in much greater numbers in diseases such as Alzheimer’s disease, leading some researchers to speculate that there may be a link between normal brain aging and pathological brain aging having to do with the speed and number of changes, not in the kind of changes that occur.
What Age-Related Changes Occur in Neurotransmitters?
As noted earlier, because neurons do not touch each other, much of the information transmission from one neuron to another occurs chemically via neurotrans- mitters. Advances have also been made in measuring changes in neurotransmitters in the aging brain. Let’s explore some of the key findings.
Dopamine. One neurotransmitter that has received a great deal of attention is dopamine. Dopamine is a neurotransmitter associated with higher-level cogni- tive functioning like inhibiting thoughts, attention, and planning, as well as emotion, movement, and pleasure and pain. Collectively, the neurons that use dopamine are called the dopaminergic system . For example, high dopamine levels are linked to cognitive processing that is effortful and deliberate, but not to the processes that are more automatic and less effortful. To investigate dopamine, the majority of studies have used postmor- tem analyses (i.e., analyses during autopsies), results from neuropsychological tests, and simulated model- ing and the imaging of dopamine activity. Bäckman et al. (2006) concluded that there is clear evidence that effective functioning of the dopaminergic system declines in normal aging. Exactly what does this mean?
Declines in the dopaminergic system are related to declines in several different aspects of memory (Nyberg, et al., 2012), such as episodic (short-term) memory and memory for information acquired in tasks that must be performed quickly, and the amount of information that can be held in mind at any given moment (called working memory). As we shall see in Chapter 6 , these are cognitive tasks that are effortful and not automatic. Fewer age differences are observed in more automatic tasks, like judging the familiarity of
information. Overall, the studies using neuroscience methods to examine changes in the dopaminergic sys- tem with increasing age suggest that these changes play a role in cognitive aging.
Other Neurotransmitters. The neurotransmitter serotonin is involved in several types of brain pro- cesses, including memory, mood, appetite, and sleep. Abnormal processing of serotonin has been shown to be related to cognitive decline both in normal aging and in Alzheimer’s disease, as well as other disor- ders such as schizophrenia (Rodriguez, Noristani, & Verkhratsky, 2012). In Chapter 10 , we will return to the role of serotonin in mental disorders.
Another important neurotransmitter related to aging is acetylcholine. In the brain, acetylcholine has an important role in arousal, sensory perception, and sustaining attention (Ando, 2012). Damage to the brain structures that use acetylcholine is associated with serious memory declines such as those found in Alzheimer’s disease.
What Age-Related Changes Occur in Brain Structures?
As you already know from observation or personal expe- rience, our bodies undergo visible changes with age. Chapter 3 will provide additional detail. The brain is no exception. Documenting those changes, however, has not been direct until the past decade. As a result, the majority of studies examining structural changes in the brain as we grow older have applied a correlational approach by employing postmortem analyses of adults’ brains.
More recently, researchers have been able to use cross-sectional and longitudinal designs to examine age differences in the brain using brain imaging tech- niques. In these studies, different regions of the brain are examined in terms of various structural changes and deficiencies, such as thinning and shrinkage in volume and density, and the declining health of the brain’s white matter, or white matter hyperintensi- ties (WMH). White matter refers to neurons that are covered by myelin that serve to transmit information from one part of the cerebral cortex to another or from the cerebral cortex to other parts of the brain. White matter hyperintensities (WMH) are determined by the observation of high signal intensity or a bright spotty
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40 CHAPTER 2
appearance on images, which indicate brain pathologies such as neural atrophy (Nordahl, Ranganath, Yoneli- nas, DeCarli, Fletcher, & Jagust, 2006).
Overall, postmortem and neuroimaging stud- ies demonstrate that many changes occur with age. One important change is that considerable shrinkage occurs in the brain by late life. However, this shrink- age is selective (Juraska & Lowry, 2012). For exam- ple, the prefrontal cortex, the hippocampus, and the cerebellum show profound shrinkage. In contrast, the areas of the brain related to sensory functions, such as the visual cortex, show relatively little shrinkage.
The white matter area also shows deterioration with increasing age. A neuroimaging method called diffusion tensor imaging (DTI) assesses the rate and direction that water diffuses through the white mat- ter. This results in an index of the structural health of the white matter (Madden et al., 2012). By using DTI, studies examining WMH have demonstrated that deterioration of white matter may represent a cause of increased prefrontal cortex dysfunction in older adults. As we will see later, deterioration of the pre- frontal cortex has important implications for cognitive functioning in late adulthood. Of equal importance is the fact that WMH are linked to cerebrovascular dis- eases (e.g., stroke resulting from hypertension), which are preventable and can be treated through medication and changes in lifestyle.
What Do Structural Brain Changes Mean? As you were reading about the structural changes that occur in the brain with age, you probably were won- dering what these changes mean in terms of behavior, especially cognitive functioning. As we will discover later in this book, with increasing age, many facets of thinking, learning, and remembering become less effi- cient and effective. So it should not be surprising that executive functioning and other aspects of cognition have received most of the attention in cognitive neuro- science and aging research.
Linking Structural Changes with Executive Func- tioning. Understanding how changes in brain struc- tures affect behavior involves careful linking of specific brain structures to specific behaviors. First, it is neces- sary to carefully describe the target behavior. Second, careful documentation of structural changes in the
brain is necessary. Third, the two sets of data need to be studied to establish the link.
Executive functioning is a good example, as its various aspects are well described. Among the most studied aspects of executive functioning are processes such as the ability to control what one is thinking about at any specific point in time, and the ability to focus on relevant information and eliminate the irrele- vant. Executive functioning failures in older adults can result in the erroneous selection of irrelevant informa- tion as relevant, the inability to divert attention away from irrelevant information to the task at hand, and inefficiency in switching tasks, among others (Alexan- der et al., 2012). For example, when older adults are reading an article that is filled with information some of which is true and some of which is false, even if they are told which information is false they still have a dif- ficult time factoring out the false information in their understanding of the article.
Poor performance on executive functioning tasks has been linked to decreased volume of the pre- frontal cortex (Juraska & Lowery, 2012). Evidence also suggests that WMH in healthy older adults who show no signs of serious cognitive disease (such as Alzheimer’s disease) have been linked to lower cog- nitive test scores and decreased executive function- ing (Madden et al., 2012). Age-related decline in the functioning of blood vessels in the brain may affect white matter structures that underlie all the areas important to executive functioning. Finally, how well one acquires new skills has been linked to the volumes of the prefrontal cortex and cerebellum (Juraska & Lowery, 2012).
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 41
Linking Structural Changes with Memory. Simi- lar research has examined links between memory and specific structural changes in the brain. For example, reductions in volume in the hippocampus are related to memory decline (Juraska & Lowery, 2012).
Much research has examined specific areas in the temporal lobe (located above the ear) and its influence on memory by examining people with Alzheimer’s dis- ease (a type of dementia described in detail in Chap- ter 10 ). For example, atrophy (very severe shrinkage), many types of abnormal neurons, and large losses of neurons are observed in this region of the brain in persons with Alzheimer’s disease, who also show pro- found memory impairment (Juraska & Lowery, 2012). Interestingly, research on older adults who do not show serious cognitive declines like those seen in Alzheim- er’s disease, but who are older than those studied who had Alzheimer’s disease, has found similar correlations
between temporal lobe atrophy and typical declines in memory performance seen in late life. Could Alzheim- er’s disease be an acceleration of normal aging pro- cesses as opposed to a separate disease process? We will take up this question again in Chapter 10 .
Linking Structural Changes with Emotion. As we have just seen, the typical age-related changes observed in executive functioning and memory map onto age-related deterioration in specific brain structures. Let’s now take a closer look at another very important aspect of the human experience—emotion—and see how structural brain changes affect it. To begin, let’s consider an example of how neuroimaging research helps establish linkages between brain structures and behavior, in this case, emo- tion. An excellent example of how this research is done is a study by Winecoff and her colleagues (2011) described in the How Do We Know? feature.
HOW DO WE KNOW?: THE AGING EMOTIONAL BRAIN Who were the investigators, and what was the aim of the study? Very little research has examined the spe- cific underlying neural mechanisms of emotion. Wine- coff and her colleagues (2011) decided to examine these mechanisms and discover whether they differed with age.
How did the investigators measure the topic of interest? Winecoff and her colleagues used a battery of tests to measure cognitive performance and emotional behavior. They tested participants’ immediate recall, delayed recall, and recognition. They also administered a response-time test to measure psychomotor speed, and a digit-span test to measure working memory. (A digit-span test is one in which strings of random dig- its are presented and the participant has to remember them in order. The longest number of digits the person can remember is called the “digit-span.”) The research- ers also had participants complete three questionnaires to measure various types of emotions.
After these measures were obtained, participants were given the cognitive reappraisal task depicted in Figure 2.3 . In brief, participants learned a reappraisal strategy that involved thinking of themselves as an emotionally detached and objective third party. Dur- ing the training session, they told the experimenter how they were thinking about the image to ensure
task compliance, but they were instructed not to speak during the scanning session. This instruction was given to ensure that the brain activity measured was related to thinking, and not to the brain activity neces- sary to move one’s tongue and mouth during speech, for example. During the functional magnetic reso- nance imaging (fMRI) session, participants completed 60 positive image trials ( 30 “Experience” and 30 “Reap- praise”), 60 negative image trials ( 30 “Experience” and 30 “Reappraise”) trials, and 30 neutral image trials (all “Experience”). Within each condition, half of the images contained people, and the other half did not. The fMRI session provided images of ongoing brain activity.
Who were the participants in the study? The sample consisted of 22 younger adults (average age = 23 years, range = 19 − 33 years) and 20 older adults ( average age = 69 years; range = 59 − 73 years) . Participants were matched on demographic variables including education. Participants received the cogni- tive, memory, and emotion tests on one day, and the reappraisal task in the fMRI session on a second day. Participants were paid $ 55 .
What was the design of the study? The study used a cross-sectional design, with testing of two age groups over two sessions.
Were there ethical concerns with the study? All participants provided written consent under a protocol approved by the Institutional Review Board of Duke University Medical Center.
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42 CHAPTER 2
What were the results? Younger and older adults performed the reappraisal tasks similarly; that is, in the reappraisal condition, positive images were reported as less positive and negative images were reported as less negative. However, older adults’ reports of negative emotion were higher than those of younger adults in the negative reappraisal situation.
Examination of the fMRI results showed that reap- praisals involved significant activation of specific areas in the prefrontal cortex for both positive and negative emotions. For both age groups, activity in the prefrontal area increased, and activity in the amygdala decreased during the reappraisal phase. These patterns are shown in Figure 2.4 . As you can see in the top figure, certain areas in the prefrontal cortex showed a pattern of acti- vation that followed participants’ self-reports of emo- tion regulation. Shown here are activation patterns in the contrast between “Reappraise-Negative” and “Experience-Negative” conditions. The graph shows
that for both positive and negative stimuli, and for both younger and older adults, prefrontal activation increased in “Reappraise” (reap) trials compared to “Experience” (exp) trials. In contrast, the lower graph shows that in the amygdala (amy) there was a systematic decrease in activation during emotion regulation between “Experi- ence-Negative” and “Reappraise-Negative” conditions.
Additional analyses of the fMRI data showed that emotion regulation modulates the functional interac- tion between the prefrontal cortex and the amygdala. Younger adults showed more activity in the prefrontal cortex during “Reappraise” trials for negative pictures than older adults did. Cognitive abilities were related to the degree of decrease in amygdala activation, inde- pendent of age.
What did the investigators conclude? Winecoff and her colleagues concluded that the prefrontal cortex plays a major role in emotional regulation, especially for older adults. In essence, the prefrontal
Figure 2.3 Cognitive reappraisal task. Participants were trained in the use of a reappraisal strategy for emotional regulation. (A) On “experience” trials, participants viewed an image and then received an instruction to experience naturally the emotions evoked by that image. The image then disappeared, but participants continued to experience their emotions throughout a 6 -second delay period. At the end of the trial, the participants rated the perceived emotional valence of that image using an eight-item rating scale. (B) “Reappraise” trials had similar timing, except that the cue instructed participants to decrease their emotional response to the image by reappraising the image (e.g., distancing themselves from the scene). Shown are examples of images similar to those of the negative (A) and positive (B) images used in the study. Source: Winecoff, A., LaBar, K. S. Madden, D. J., Cabeza, R., & Huettel, S. A. (in press). Cognitive and Neural Contributions to Emotion Regulation in Aging. Social Cognitive and Affective Neuroscience, 6. By permission of Oxford University Press.
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 43
cortex may help suppress (regulate) emotions in the same way as that area of the brain is involved in inhibiting other behaviors. Importantly, the degree of emotional regulation was predicted by cognitive ability, with higher cognitive ability associated with higher emotional regulation. This may mean that as cognitive abilities decline, people may be less able to regulate their emotions, a pattern typical in such dis- eases as dementia. Thus, not only is there evidence of underlying brain structures playing critical roles in
emotion regulation, but there may be a neurological explanation for the kinds of emotional outbursts that occur in dementia and related disorders.
What converging evidence would strengthen these conclusions? Winecoff and her colleagues stud- ied only two age groups of healthy adults and did not include either old-old participants or adults with demonstrable cognitive impairment. It will be impor- tant to study these groups to map brain function changes and behavior more completely.
Figure 2.4 Modulation of prefrontal and amygdalar activation by emotion regulation. Source: Winecoff, A., LaBar, K. S. Madden, D. J., Cabeza, R., & Huettel, S. A. (in press). Cognitive and Neural Contributions to Emotion Regulation in Aging. Social Cognitive and Affective Neuroscience, 6. By permission of Oxford University Press.
How does emotional processing change across adulthood? The quick answer is that it’s complicated (Kaszniak & Menchola, 2012). In general, research shows that adults of all ages report about the same range and experience of emotion. But there is also evidence that changes in brain activity in the prefrontal cortex and the amygdala with age may be related to a decrease in processing of negative emotional information and an increase in processing of positive emotional informa- tion with age. These differences tend to be interpreted as reflecting increased emotional regulation with age;
in other words, older adults tend to be able to regulate their emotions better than younger adults. This may be due to a desire on the part of people as they age to develop closer, more meaningful relationships that generate positive emotions, while avoiding people and situations that generate negative ones.
Cognition and emotion interact. Kensinger and colleagues (Kensinger, 2012; Kensinger & Cor- kin, 2006) propose two distinct cognitive and neural processes that contribute to emotional processing and memory. The difference depends upon how
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44 CHAPTER 2
emotionally arousing the information is. Processing of negative high-arousal information for memory is rela- tively automatic in nature and is linked to activation of the amygdala as it interacts with the hippocampus to support memory performance. For memory pro- cessing of negative low-arousal stimuli, more activa- tion of the prefrontal cortex–hippocampus network is necessary.
Kensinger (2012) argues that whether emotional arousal enhances memory depends on the engagement in emotion-specific processes that are linked to these distinct neural processes. So when a person accurately remembers negative high-arousal items, this corre- sponds to increased activation of the amygdala and prefrontal cortex. Other studies support this conclu- sion. For instance, if the amygdala is damaged, indi- viduals do not attend to arousing stimuli.
How do structural and functional changes in the brain affect these processes? The short answer is that it depends (Fossati, 2012; Lee & Siegle, 2012; Ray & Zald, 2012). Older adults show more brain activity between the prefrontal cortex and the medial tempo- ral lobe than younger adults do, regardless of whether the content is emotionally positive or negative. These increases in connections may be due to age-related changes that occur in the prefrontal cortex that make it necessary for older adults to use more connections to process the information (Waring, Addis, & Kensinger, 2013). We’ll return to this need for extra connections a bit later when we consider the notion of whether older adults compensate for brain changes.
Linking Structural Changes with Social-Emotional Cognition. What happens in the brain when things get even more complicated, such as when we have to process complex situations that involve social judg- ments, when memory, emotion, and previously learned information come together? The story begins in the early 2000s, when researchers first outlined a social cognitive neuroscience approach to attributional infer- ences, or how people make causal judgments about why social situations occur (e.g., Lieberman, Gaunt, Gilbert, & Trope, 2002). That work identified a social judgment process that involves a relatively automatic system in which people read cues in the environment quickly and easily, without deliberation, and then make social judgments.
For example, if someone is staggering down the hallway, we may automatically assume the person is intoxicated without taking into consideration many other factors that might cause someone to stag- ger (e.g., he is injured, he is experiencing a medical emergency). In other words, we have a tendency to automatically put the person into a preexisting social category. We base this judgment on easily activated, well-practiced categories of information based on our past experiences and current goals, and we do this most prominently when the situation is ambiguous. In such situations, we are unlikely to consider alternative explanations.
What’s intriguing is that researchers have pre- sented compelling evidence that drawing these kinds of quick conclusions in ambiguous situations is prob- ably a result of how our brains are wired. It turns out that we have specialized areas in the brain, such as the lateral temporal cortex, amygdala, and basal ganglia, that are associated with automatic social cognition (Fossati, 2012; Lee & Siegle, 2012).
Researchers also have identified another sys- tem that underlies a more deliberative form of social cognitive judgments that employs symbolic logic and reflective awareness. The neural basis of these more reflective judgments appears to reside in the prefrontal cortex, the anterior cingulate cortex, and the hippo- campus (Lee & Siegle, 2012).
So how do these different brain pathways change with age, and what difference does that make? The brain structures involved in more automatic processing (e.g., the amygdala) show less age-related deterioration, whereas those involved in more reflective processing (e.g., the prefrontal cortex) show more severe dete- rioration. Based on these findings, we would expect that older adults might tend to rely more on automatic processes.
Complex Development in the Prefrontal Cortex. There is no question that neuroscience research points to the central role played by the prefrontal cortex in adult development and aging. This part of the brain is intimately involved in the most important aspects of thinking and reasoning, including executive function- ing, memory, and emotion. So it is probably not sur- prising to discover that at a detailed level, age-related changes in the prefrontal cortex are complex.
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 45
The most important arena in this complex pat- tern is in the interface between emotion and memory. We have already seen that brain pathways involved in memory tend to deteriorate with age, whereas key pathways involved in emotion do not. How is this explained?
Let’s start by focusing on a well-documented effect, the positivity effect. The positivity effect refers to the fact that older adults are more motivated to derive emotional meaning from life and to maintain positive feelings (Isaacowitz & Blanchard-Fields, 2012; Scheibe & Carstensen, 2010). As a result, older adults are more likely than younger adults to attend to the emotional meaning of information.
Research shows that in addition to some common brain areas that process all emotion, there are also some unique pathways; for instance, positive emotional pro- cessing occurs in different brain regions from negative emotional processing (Fossati, 2012; Kensinger, 2012). Some of these pathways are the same for all adults. Specifically, the common pathways in emotion pro- cessing for adults of all ages include the amygdala and the part of the prefrontal cortex right behind the eyes (the lateral orbitofrontal cortex). For positive emotion processing, other parts of the front of the prefrontal cortex are involved. For negative emotion processing, the temporal region is brought into action instead.
But there are some important age-related differ- ences in brain pathways, too, that help us understand age-related differences in emotion-related behaviors. When older adults process information that is emo- tionally positive, they also show increased activity in the middle portion of the prefrontal cortex, the amyg- dala, and the cingulate cortex (a structure that forms a “collar” around the corpus callosum). Bringing addi- tional areas of the brain into play during processing is a phenomenon we will return to a bit later.
These age-related changes in how the brain pro- cesses positive and negative emotional information shows both that there are probably underlying struc- tural changes in the brain that result in age-related differences in behavior, and that these structural changes can be quite nuanced and complex. Addi- tionally, neuroimaging research has drawn attention to the truly central and critical role played by the pre- frontal cortex in understanding why people are the way they are.
2.3 Making Sense of Neuroscience Research: Explaining Changes in Brain-Behavior Relations
LEARNING OBJECTIVES What is the Parieto-Frontal Integration Theory,
and what does it explain? How do older adults attempt to compensate for
age-related changes in the brain? What are the major differences among the
HAROLD, CRUNCH, and STAC models of brain activation and aging?
We have considered evidence that structural and neurochemical changes occur in the brain as we grow older, and that these changes in the brain relate to changes in cognitive functioning. With that as back- ground, let’s now reconsider research that is based on the functional brain imaging techniques, such as fMRI, that we noted earlier.
The main point of functional brain imaging research is to establish how age-related deterioration in specific brain structures affects a person’s ability to per- form various tasks, measuring both at the same time.
A second aim of these types of studies, and the point of this section, is to identify patterns of how the brain is sometimes able to compensate for negative age- related changes by activating different or additional regions when tasks pose a distinct difficulty. In other words, older and younger adults may differ in terms of which regions of the brain are used in order to perform cognitive tasks more effectively. On the one hand, these compensation strategies could result in roughly equiv- alent performance despite other differences across age. On the other hand, these compensation strategies could be ineffective and could reveal the neurologi- cal underpinnings of the cognitive decline observed in older adults. Which of these outcomes occurs not only has important consequences for performance on
Adult Development in Action You are a health care worker and a specialist in geri- atric medicine. One of your clients shows significant declines in memory and executive functioning. What brain structures and processes might you want to examine closely for evidence of age-related change?
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46 CHAPTER 2
research tasks, but also in how well older adults might adapt to challenges in their daily lives.
The Parieto-Frontal Integration Theory The typical finding is reduced brain activity in older as compared to younger adults in prefrontal and tem- poral areas that support cognitive functioning, such as memory (Juraska & Lowery, 2012). However, we also know that there is a marked increase in activity in specific areas of the prefrontal cortex and other brain regions during certain tasks, specifically memory for emotional material, in older adults as compared to younger adults (Grady, 2012; Spaniol & Grady, 2012). We will come back to this discrepancy a bit later.
There’s more, though. Grady (2012; Spaniol & Grady, 2012) points out that reduced prefrontal recruitment in aging is context-dependent. That is, older adults sometimes show reduced activation or recruitment of the appropriate prefrontal regions, and sometimes show the same or more recruitment com- pared to younger adults depending on the tasks they are doing at the time.
Given the pivotal role played by the prefrontal cor- tex in such a wide range of cognitive tasks, researchers are homing in on its role in explaining intelligence at a holistic level. Research now shows that the prefron- tal cortex, along with the parietal lobe (an area of the brain at the top of the head), plays an important role in general intellectual abilities. Based on 37 studies using various types of neuroimaging techniques, Jung and Haier (2007) proposed the Parieto-Frontal Integra- tion Theory. The Parieto-Frontal Integration Theory (P-FIT) proposes that intelligence comes from a distrib- uted and integrated network of neurons in the parietal and frontal areas of the brain . Figure 2.5 . Shows these key brain areas. In general, P-FIT accounts for individ- ual differences in intelligence as having their origins in individual differences in brain structure and function.
The P-FIT model is an example of theories based on neuroscience research, and has been tested and sup- ported in several studies. It is clear that performance on specific measures of intelligence, including many of those that we will consider in detail in Chapter 7 , are quite likely related to specific combinations of brain structures (Haier et al., 2010).
Finally, there is also considerable research show- ing the central role that the prefrontal cortex plays in
integrating cognition and emotion (Ray & Zald, 2012): specifically, how different areas within the prefrontal cortex connect to two other key areas of the brain, the limbic system and the amygdala, influence how we process emotional content, as we have seen.
Given different patterns of brain activation across adulthood for certain tasks, the question arises whether these differences reflect adaptive behavior as people age. That’s the issue we’ll consider next.
Can Older Adults Compensate for Changes in the Brain?
We have seen that differences in brain activation have been documented between younger and older adults, and that these differences relate to differences in performance. There’s an additional, and interesting, nuance to these findings. For example, it turns out that it is not simply that older adults show reduced acti- vation in regions associated with a particular cogni- tive task. Rather, studies focusing on verbal working memory and long-term memory show focal, unilateral activity in the left prefrontal region in younger adults but bilateral activation (i.e., in both the left and right prefrontal areas) in older adults when performing the same tasks (Grady, 2012; Spaniol & Grady, 2012).
These findings surprised researchers, and ushered in much discussion and research as to what this meant
Figure 2.5 The P-FIT Model indicates that integration of the parietal and frontal lobes underlies intelligence.
Parietal lobe
Frontal lobe
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 47
Theories of Brain-Behavior Changes Across Adulthood
As we have seen, several studies have shown evidence for different patterns of brain activity in specific regions in older adults across numerous cognitive tasks, sug- gesting that the underlying brain changes are not overly specific to a narrow set of circumstances (e.g., Grady, 2012). Additional age-related neural activa- tion (especially in prefrontal areas) may be functional and adaptive for optimal performance as people grow older. Researchers now suggest that these activation patterns may reflect an adaptive brain that functionally reorganizes and compensates for age-related changes (Spaniol & Grady, 2012; Sun, Tong, & Yang, 2012).
A number of models have been used to attempt to explain these findings. Three of the most prominent are the HAROLD model by Cabeza (2002), the CRUNCH model developed by Reuter-Lorenz and her colleagues (Reuter-Lorenz, 2002; Reuter-Lorenz & Mikels, 2006), and the STAC model (Park & Reuter-Lorenz, 2009). These models make a common assumption: The pri- mary reason for greater activation in different brain regions, as well as for the different patterns within the prefrontal cortex, is the need for the recruitment of additional brain regions in order to successfully exe- cute cognitive functions as one grows older.
The HAROLD Model. Numerous studies have docu- mented the fact that younger adults show brain activa- tion in one brain hemisphere when performing various cognitive tasks, but that older adults’ brains tend to show increased activation in both brain hemispheres. Explaining this difference led to the development of the HAROLD model. The HAROLD model stands for
for the aging brain. Is the older brain working to com- pensate for deterioration in these focal regions related to the cognitive task? Is the older brain working harder and recruiting more brain structures, or is the bilat- eral activation merely the inefficient operation of poor inhibition of irrelevant information that turns the acti- vation into interference of optimal functioning (Park & Reuter-Lorenz, 2009)?
The answer appears to be yes—older adults are compensating. Researchers concluded that this bilateral activation in older adults may serve a functional and supportive role in their cognitive functioning (Grady, 2012; Park and Reuter-Lorenz, 2008). Supportive evidence comes from the associa- tion between bilateral activation in older adults and higher performance, evidence not found in younger adults, across a number of tasks including category learning tasks, visual field tasks, and various mem- ory tasks.
Figure 2.6 shows that there is greater prefrontal bilateral activity in older adults during working mem- ory tasks than in younger adults. On the left side of the figure, you can see that there is left-lateralized prefron- tal engagement in younger adults, whereas older adults also engage the right prefrontal areas. The right side demonstrates that younger adults and low-performing older adults show right-lateralized activation during a long-term memory task. Interestingly, high-perform- ing older adults still show bilateral prefrontal engage- ment. It may be that high-functioning older adults are more adept at compensating for normative deteriora- tion in the brain by utilizing other areas of the brain. Whether or not this is an accurate conclusion is still being debated.
Figure 2.6 Prefrontal bilateral activation increases with age. Source: Park, D. C., & Reuter-Lorenz, P. (2008). The Adaptive Brain: Aging and Neurocognitive Scaffolding. Copyright 2009, Reprinted with permission from the Annual Review of Psychology, Volume 60, www.annualreviews.org
Younger Adults—Verbal Working Memory
Young
Old-Low
Old-High
Older Adults—Verbal Working Memory
More frontal bilateral activity in older adults during a verbal working memory task (left) and in older adults with higher performance in a long-term memory task (right)
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48 CHAPTER 2
Hemispheric Asymmetry Reduction in OLDer adults that explains the empirical findings of reduced lateral- ization in prefrontal lobe activity in older adults (that is, the reduced ability of older adults to separate cogni- tive processing in different parts of the prefrontal cortex) (Cabeza, 2002; Collins & Mohr, 2013). It suggests that the function of the reduced lateralization is compensa- tory in nature; that is, additional neural units are being recruited and used to increase attentional resources, processing speed, or inhibitory control.
The HAROLD model has been supported by several studies that show how the brain creates and uses reserve abilities to lessen the impact of age-related changes in the brain (e.g., Cabeza & Dennis, 2013; Collins & Mohr, 2013; Steffener & Stern, 2012). What remains to be established, though, is where the line should be drawn separating normal age-related changes that can be com- pensated and changes that are so extensive or are hap- pening so rapidly that compensation does not work.
The CRUNCH Model. The CRUNCH model stands for Compensation-Related Utilization of Neural Circuits Hypothesis, and describes how the aging brain adapts to neurological decline by recruiting additional neural circuits (in comparison to younger adults) to perform tasks adequately (DeCarli et al., 2012; Reuter-Lorenz, 2002; Reuter-Lorenz & Mikels, 2006). Like the HAR- OLD model, the CRUNCH model incorporates bilat- erality of activation. But the CRUNCH model suggests this is not the only form of compensation. Two main mechanisms are suggested that the older brain uses to perform tasks: more of the same and supplemen- tary processes. More of the same means that when task demands are increased, more activation can be found in the same brain region that is activated for process- ing easier tasks. This effect can be found in younger as well as older adults. However, in older adults, neural efficiency declines, so additional neuronal circuits are recruited earlier than they are in younger adults.
Supplementary processes take place when different brain regions are activated to compensate for lacking or insufficient processing resources. Reduced lateralization is one way of recruiting additional resources because both hemispheres are called into action rather than just one. In addition, however, compared to younger adults’ brains older adults’ brains also show overactivation in different brain regions. This happens when the acti- vation level in older adults’ brains occurs in the same
regions as in younger adults’ brains, but at a significantly higher level. These patterns suggest that compensation can take different forms in the aging brain.
The CRUNCH model also has considerable sup- port (e.g., DeCarli et al., 2012; Grady, 2012). However, just as is true about the HAROLD model, the point at which compensation breaks down is not well estab- lished under the CRUNCH model.
The STAC Model. How do we explain the specific pat- terns of age-related changes in prefrontal activity? To answer that question, Park and Reuter-Lorenz (2009) proposed the STAC model, shown in Figure 2.7 . The Scaffolding Theory of Cognitive Aging (STAC) model is based on the idea that age-related changes in one's ability to function reflect a life-long process of compen- sating for cognitive decline by recruiting additional brain areas (Goh & Park, 2009). As we will see especially in Chapters 6 and 7 , aging is associated with both decline as well as preservation of various cognitive abilities. The STAC model explains neuroimaging studies that show selective changes in the aging brain that reflect neural decline as well as compensatory neural recruit- ment, especially in the prefrontal cortex.
From the perspective of the STAC model, what’s the purpose of the compensation? For one thing, there is growing evidence that the increase in frontal activ- ity in older adults may be a response to decreased effi- ciency of neural processing in the perceptual areas of the brain (Park & Reuter-Lorenz, 2009).
There’s another reason, too. Remember how the prefrontal region helps suppress irrelevant informa- tion that may interfere with the task one is actually performing? It turns out that older adults have trouble suppressing what’s referred to as the default network of the brain. The default network of the brain refers to regions of the brain that are most active when one is at rest. One example of this would be the brain activ- ity occurring when an individual lies quietly and is not directly engaged in a cognitive task (Andrews-Hanna, 2012). When a younger adult begins a demanding cognitive task, this default network is suppressed. But older adults display less suppression of this default network, resulting in poorer performance (Andrews- Hanna, 2012; Grady, 2012). Thus, this failure to shift from a resting state to a more active state to engage in cognitive processing may be another reason for increased frontal activity in older adults as a way to
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 49
“work around” the lack of suppression (Grady, 2012; Juraska & Lowery, 2012).
The STAC model (Park & Reuter-Lorenz, 2009) suggests that the reason older adults continue to per- form at high levels despite neuronal deterioration is because they create and rely on a back-up neural path- way. It works like this. When you learn a new task, learn- ing moves from effortful processing (learning is hard work!) to overlearning (more automatic, less effortful processing). The neurological shift that happens in a young adult is from a broader dispersed network (which Park and Reuter-Lorenz call the scaffold ) used while learning to a more focal, efficient, and optimal neural circuit. In older adults, though, the initial scaffolding remains available as a secondary, back-up circuit that can be counted on when necessary. Scaffolded networks are less efficient than the honed, focal ones they used as
young adults, so on average poorer performance is the result. But enough of the time, information is remem- bered eventually. The trade-off is that without the scaf- folding, performance would be even worse because older adults would have to rely on the more focal areas.
The elegance of the STAC model is that older adults’ performance can be understood in terms of fac- tors that impact decline and those that impact compen- sation. As Park and Reuter-Lorenz (2009) argue, this integrative approach embraces a lifelong potential for plasticity and the ability to adapt to age-related changes.
In sum, neuroscience has opened new avenues of understanding aging. Advances in neuroscien- tific methods allow us to adequately test conditions under which age-related structural change in the brain is associated with decline, compensation, or even improvement in functioning. Rather than using general
Figure 2.7 Conceptual model of the Scaffolding Theory of Cognitive Aging. Source: Park, D. C., & Reuter-Lorenz, P. (2008). The Adaptive Brain: Aging and Neurocognitive Scaff olding. Copyright 2009, Reprinted with permission from the Annual Review of Psychology, Volume 64.
• Shrinkage
• White Matter Changes
• Cortical Thinning
• Dopamine Depletion
• Dedifferentiation of Ventral Visual Area
• Decreased Medial Temporal Recruitment
• Increased Default Activity
• New Learning
• Engagement
• Exercise
• Cognitive Training
• Frontal Recruitment
• Neurogenesis
• Distributed Processing
• Bilaterality Neural
Challenges
Aging
Functional Deterioration
Scaffolding Enhancement
Level of Cognitive Funtion
Compensatory Scaffolding
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50 CHAPTER 2
biological deterioration as the default explanation for behavioral changes, we can now identify specific brain mechanisms that are reflected in different structures of and activation patterns in the brain. These techniques have also allowed us to differentiate preserved areas of the brain from areas that are more prone to decline.
time. Leticia’s observations of the positive changes that took place after she started playing the Wii video game are a good example of this plasticity.
Plasticity provides a way to understand compensa- tory changes in both the more observable behavior and the less observable (without neuroimaging, anyway) reor- ganization of neural circuitry in the brain. Many attempts have been made to assess the potential for plasticity in cognitive functioning by focusing on ways to improve cognitive performance through training (a good example of which would be Leticia’s practice on the video game).
Baltes and colleagues’ now classic research set the standard for documenting the range of plasticity in older adults’ cognitive performance (e.g., Baltes & Kliegl, 1992; Willis, Bliezner, & Baltes, 1982). They found that whereas older adults are able to improve cognitive ability in memory tasks through tailored strategy training beyond the level of untrained younger adults, this is highly task- specific, and the ability-level gains are very narrow in focus.
Since these early findings, research has shown that basic cognitive processes affected by aging can indeed be improved through training, and that they transfer to multiple other kinds of functioning as long as the tasks share the same basic underlying functions (e.g., Dah- lin, Neely, Larsson, Bäckman, & Nyberg, 2008). From a neural plasticity perspective, research on neural stem cells has revealed compelling evidence that demon- strates the effects of experience on various aspects of brain functioning in adulthood and aging (Fuentealba, Obernier, & Alvarez-Buylla, 2012; Ruckh et al., 2012). Neural stem cells are cells that persist in the adult brain and can generate new neurons throughout the life span. The discovery of neural stem cells proved wrong the long-standing belief that neurogenesis (i.e., the devel- opment of new neurons) dwindles away at the end of embryonic development. In practical terms, it means that you certainly can teach an old dog new tricks.
All of this research adds a new level of understand- ing to what happens to individuals as they grow older. For example, even though aging is associated with an overall decrease in the number of new neurons, this differs across regions of the brain and may be altered even at advanced ages.
The big question, of course, is whether the dis- covery of neural stem cells and the fact that neurons can regenerate even in late life means that neurosci- ence research could be used to cure brain diseases and
Adult Development in Action You are an activity therapist at a senior center, and want to design activities for the members that will help them compensate for typical age-related cogni- tive changes. Using the theories described in this sec- tion, what would an example of a good activity be?
2.4 Neural Plasticity and the Aging Brain LEARNING OBJECTIVES
What evidence is there for neural plasticity? How does aerobic exercise influence brain
changes and cognitive aging? How does nutrition influence brain changes and
cognitive activity?
Marisa has been playing incessantly with her lat- est Nintendo Wii video game. Her grandmother, Leti- cia, became captivated by her granddaughter’s gaming and asked her granddaughter to teach her how to do it. Marisa was delighted and helped her grandmother learn the game. After months of practice, Marisa noted that her grandmother seemed stronger in her normal physi- cal activities and her perceptual skills seemed to have improved. In addition, Leticia and her granddaughter Marisa had more in common than ever before.
There’s an old saying that “You can’t teach an old dog new tricks.” Even if that’s true for dogs, is it true for peo- ple? Neuroscience research helps provide some answers.
As discussed earlier in this chapter, there are cer- tain situations in which the brain itself compensates for age-related changes. As was noted then, compensation is based on the notion that there is plasticity in both brain changes and behavior across the adult life span. Plasticity involves the changes in the structure and func- tion of the brain as the result of interaction between the brain and the environment. In other words, plasticity is the result of people and their brains living in the world and accumulating and learning from experiences over
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 51
Exercise and Brain Aging Some of the most compelling work that has moved beyond the mere documentation of plasticity to the actual improvement of cognitive skills and concomi- tant changes in the brain focuses on the influence of aerobic exercise. Overall, research shows clearly that brain plasticity is enhanced as a result of aerobic exer- cise (Thomas, Dennis, Bandettini, & Johansen-Berg, 2012), and some studies have even shown that aerobic exercise can counter the declines in the hippocampus associated with Alzheimer’s disease (Erickson et al., 2009; Intlekofer & Cotman, 2013).
An example of this line of research is a study by Erickson and his colleagues (2009). They were interested in learning whether aerobic exercise had any effect on the volume of the hippocampus, a key brain structure connected to memory. Erickson and colleagues had older adults exercise on a motorized treadmill, while their respiration, blood pressure, and
CURRENT CONTROVERSIES: ARE NEURAL STEM CELLS THE SOLUTION TO BRAIN AGING? Imagine if you could replace brain cells that had either died or had been damaged? That’s the goal of researchers who study neural stem cells. Clearly, this research would fundamentally change our under- standing of aging and of brain disease.
Research on the potential of neural stem cells took a major leap forward in 2007 with the founding of the New York Neural Stem Cell Institute. The Insti- tute’s mission is “to develop regenerative therapies for diseases of the central nervous system.” Ongoing research programs include identifying potential uses of neural stem cells in treating such diseases as amyo- trophic lateral sclerosis, Alzheimer’s disease, brain injury and stroke, macular degeneration, multiple sclerosis, optic neuropathy, Parkinson’s disease, reti- nitis pigmentosa, and spinal cord injury.
The National Human Neural Stem Cell Resource supplies researchers with neural stem cells obtained from the post-natal, postmortem, human brain.
Despite the great promise of this research, a basic question is whether it should be done at all. Several key ethical questions arise (Ramos-Zúñiga et al., 2012). This research requires that the human brain be used as an experimental object of study, and be manipu- lated in specific ways. Certainly, any such intervention, whether it is a treatment for a disease or a replace- ment of defective brain cells, requires the highest level of ethical principles. Perhaps the most difficult issue is that just because an intervention can be done, does not necessarily mean that is should be done.
As a result, researchers must go to great lengths to analyze the ethical implications of every research project involving neural stem cells, along with any potential clinical applications and outcomes. The usual medical standard of causing no harm is especially important in this research, as is a very careful assess- ment of the risk-benefit balance. But most important is keeping in the forefront of everything the fact that the research involves a human and a human brain. Aere obiobic ec exercisciscisci ee is ggooodod for mmainaintaiininng g bbrain hn heealth.t
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essentially create “new brains” (Kazanis, 2012). Per- haps, that is likely many years from now. In the mean- time, what we do know is that brain cells can regenerate, even in late life, under the right circumstances, and that the brain shows considerable plasticity to create ways for people to compensate with age-related declines in functioning. Still, this work is not without controversy, as discussed in the Current Controversies feature.
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52 CHAPTER 2
heart rate were continuously monitored. Participants also completed a spatial memory task and had an MRI to measure hippocampal volume. They found that higher aerobic fitness levels were associated with the preservation of greater hippocampal volume, which in turn was the best predictor of how well participants performed on the spatial memory task.
We will return to the many benefits of exercise in Chapter 4 . As a preview, the positive effects on the brain are only one reason to get up and exercise.
Nutrition and Brain Aging We began this chapter with a consideration of “brain food” and the claims that certain foods result in ben- efits for the brain. Thanks to neuroimaging studies, researchers are beginning to understand the relations between categories of nutrients and brain structures.
For example, Bowman and colleagues (2012) iden- tified three nutrient biomarker patterns associated with cognitive function and brain volume. Two patterns were associated with better cognitive functioning and greater brain volume: one higher in blood plasma lev- els of vitamins B (B1, B2, B6, folate, and B12), C, D, and E, and another high in blood plasma levels of omega- 3 fatty acids (usually found in seafood). A third pattern characterized by high trans fat was associated with less favorable cognitive function and less total cerebral brain volume. More detailed analyses have examined two different omega- 3 fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Samieri and colleagues (2012) showed that only the EPA type was associated with maintaining better neuronal struc- ture in the right part of the amygdala, and that atro- phy of this part of the amygdala was associated with significant declines in memory and increases in symp- toms of depression. Some additional research indicates that DHA may slow the progression of Alzheimer’s disease, but once the disease has developed the effect
Social Policy Implications The fact that the general view that the human brain gradually loses tissue from age 30 onward, and that those changes can mean poorer cognitive perfor- mance, combined with the projected rapid growth of an aging population present society with numerous public policy issues regarding the staggering costs of medical intervention and care for older adults. The good news is that advanced research in neurosci- ence tells us that this is an oversimplification of what really happens to the aging brain. Of importance to policy makers is that researchers are identifying ways in which such brain deterioration can be reduced or even reversed. In addition, researchers have identi- fied areas of the brain that are relatively preserved and may even show growth. Thus, it is important for policy makers to obtain a more complete and accu- rate picture of aging. Why?
Research in neuroscience and aging is extremely important for a wide range of social policies from health care policies to laws pertaining to renewing drivers licenses and the age at which people should be eligible for retirement benefits, among others. Federal agencies such as the National Institute on Aging have focused much of their efforts onto bet- ter ways to assess and understand changes in the brain. These efforts demand more multidisciplinary research.
A good example is the compelling research regarding the effects of aerobic exercise and diet on the aging brain and how well it functions. The old saying of “use-it-or-lose-it” appears to be true.
What’s at stake regarding policy? We are now talking about extending the vitality of older adult- hood. Evidence from neuroimaging research pro- vides a platform from which new interventions might be developed to make this a reality. However, policy makers must continue to support neuroscience research in order to keep our knowledge moving forward.
Adult Development in Action As the director of older adult services at a regional Area Office on Aging, you need to design websites about the benefits of exercise and good nutrition for older adults. What would the key information ele- ments of the Website be?
disappears (Cunnane, Chouinard-Watkins, Castellano, & Barberger-Gateau, 2013).
Although researchers are only beginning to understand how nutrition affects brain structures, the findings to date clearly show that the effects could be substantial. As with exercise, we will return to the topic of nutrition and its effects on aging in Chapter 4 .
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 53
What changes occur in neurotransmitters with age? Important declines occur in the dopaminergic sys-
tem (neurons that use dopamine) that are related to declines in memory, among others.
Age-related changes in serotonin affect memory, mood, appetite, and sleep.
Age-related changes in acetylcholine are related to arousal, sensory perception, and sustained attention.
What changes occur in brain structures with age? White matter (neurons covered by myelin) becomes
thinner and shrinks, and does not function as well with age. White matter hyperintensities (WMH) are related to neural atrophy.
Many areas of the brain show significant shrinkage with age.
What do age-related structural brain changes mean for behavior?
Structural changes in the prefrontal cortex with age cause significant declines in executive func- tioning.
Age-related structural changes in the prefron- tal cortex and the hippocampus cause declines in memory function.
Older and younger adults process emotional mate- rial differently. Older adults show more activity in more areas of the prefrontal cortex.
Brain structures involved in automatic process- ing (e.g., amygdala) show less change with age, whereas brain structures involved in more reflec- tive processing (e.g., prefrontal cortex) show more change with age.
The positivity effect refers to the fact that older adults are more motivated to derive emotional meaning from life and to maintain positive feelings. Older adults activate more brain structures when processing emotionally positive material.
2.3 Making Sense of Neuroscience Research: Explaining Changes in Brain-Behavior Relations
What is the Parieto-Frontal Integration Theory, and what does it explain?
The Parieto-Frontal Integration Theory (P-FIT) pro- poses that intelligence comes from a distributed and integrated network of neurons in the parietal and frontal areas of the brain.
Summary 2.1 The Neuroscience Approach
What brain imaging techniques are used in neuroscience research?
Structural neuroimaging such as computerized tomography (CT) and magnetic resonance imaging (MRI) provide highly detailed images of anatomical features in the brain.
Functional neuroimaging such as single pho- ton emission computerized tomography (SPECT), positron emission tomography (PET), functional magnetic resonance imaging (fMRI), magnetoen- cephalography, and near infrared spectroscopic imaging (NIRSI) provide an indication of brain activity but not high anatomical detail.
What are the main research methods used and issues studied in neuroscience research in adult development and aging?
The neuropsychological approach compares brain- related psychological functioning of healthy older adults with adults displaying pathological disorders in the brain.
The neuro-correlational approach links measures of behavioral performance to measures of neural structure or functioning.
The activation imaging approach directly links functional brain activity with behavioral data.
2.2 Neuroscience and Adult Development and Aging
How is the brain organized structurally? The brain consists of neurons, which are comprised
of dendrites, axon, neurofibers, and terminal branches. Neurons communicate across the space between neurons called the synapse via chemicals called neurotransmitters.
Important structures in the brain for adult develop- ment and aging include the cerebral cortex, corpus callosum, prefrontal and frontal cortex, cerebel- lum, hippocampus, limbic system, and amygdala.
What are the basic changes in neurons as we age? Structural changes in the neuron include declines
in number, decreases in size and number of den- drites, the development of tangles in neurofi- bers, and increases in deposits of certain proteins.
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54 CHAPTER 2
How do older adults attempt to compensate for age- related changes in the brain?
Older adults compensate for brain changes by acti- vating more areas of the brain than young adults when performing the same tasks.
What are the major differences among the HAROLD, CRUNCH, and STAC models of brain activation and aging?
The Hemispheric Asymmetry Reduction in Older Adults (HAROLD) model explains the finding of the reduced ability of older adults in separating cogni- tive processing in different parts of the prefrontal cortex.
The Compensation-Related Utilization of Neural Circuits Hypothesis (CRUNCH) model describes how the aging brain adapts to neurological decline by recruiting additional neural circuits (in comparison to younger adults) to perform tasks adequately. This model explains how older adults show overac- tivation of certain brain regions.
The Scaffolding Theory of Cognitive Aging (STAC) model is based on the idea that age-related changes in one’s ability to function reflect a life- long process of compensating for cognitive decline by recruiting additional brain areas. This explains how older adults build and rely on back-up neural pathways.
2.4 Neural Plasticity and the Aging Brain
What evidence is there for neural plasticity? Plasticity involves the changes in the structure and
function of the brain as the result of interaction between the brain and the environment. Plasticity helps account for how older adults compensate for cognitive changes.
Neural stem cells are cells that persist in the adult brain and can generate new neurons throughout the life span.
How does aerobic exercise influence brain changes and cognitive aging?
Brain plasticity is enhanced through aerobic exercise.
How does nutrition influence brain changes and cognitive activity?
Maintaining good levels of certain nutrients in blood plasma helps reduce the levels of brain struc- tural changes and cognitive declines.
Review Questions 2.1 The Neuroscience Approach
Describe structural and functional neuroimaging techniques. How do they differ?
Describe the various neuroscience methodological perspectives used to study the aging brain. What are their strengths and their limitations?
How does the neuroscience level of examination contribute to our understanding of adult develop- ment and aging?
2.2 Neuroscience and Adult Development and Aging
Describe the basic structures in the brain. What age-related changes are observed in neurons? What happens to dopamine functioning in the
aging brain? What age-related changes occur in other neurotransmitters?
What age-related changes occur in brain struc- tures? What structures play major roles in the aging process?
What are the differences in brain activation dur- ing cognitive tasks for younger and older adults? What key differences have been identified in activity in the prefrontal cortex between younger and older adults?
What age-related differences have been docu- mented in executive processing?
What differences are there in memory with age as they relate to brain activation?
How do younger and older adults process emotion- ally related material?
2.3 Making Sense of Neuroscience Research: Explaining Changes in Brain-Behavior Relations
What does P-FIT explain? What evidence is there that older adults compen-
sate for age-related changes in the brain? Compare and contrast the HAROLD, CRUNCH, and
STAC theories.
2.4 Neural Plasticity and the Aging Brain What is neural plasticity? How might neural stem
cells be used to increase neural plasticity?
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NEUROSCIENCE AS A BASIS FOR ADULT DEVELOPMENT AND AGING 55
How does aerobic exercise affect age-related brain changes?
How does nutrition affect age-related brain changes?
INTEGRATING CONCEPTS IN DEVELOPMENT Which of the theories of bilateral activation in older
adults’ brains makes the most sense to you? Why? What would you say about the stereotypes of
aging now that you understand the plasticity of brain functioning?
What does the work on brain plasticity imply for exercising the mind and body?
How would you design a cognitive training pro- gram to take advantage of age-related changes in brain structures and plasticity?
KEY TERMS activation imaging approach Attempts to directly link functional brain activity with cognitive behavioral data.
amygdala The region of the brain, located in the medial-temporal lobe, believed to play a key role in emotion.
antioxidants Compounds that protect cells from the harmful effects of free radicals.
axon A structure of the neuron that contains neurofibers.
cerebellum The part of the brain that is associated with motor functioning and balance equilibrium.
cerebral cortex The outermost part of the brain con- sisting of two hemispheres (left and right)
CRUNCH model A model that describes how the aging brain adapts to neurological decline by recruiting addi- tional neural circuits (in comparison to younger adults) to perform tasks adequately.
compensatory changes Changes that allow older adults to adapt to the inevitable behavioral decline resulting from changes in specific areas of the brain.
corpus callosum A thick bundle of neurons that con- nects the left and right hemispheres of the cerebral cortex
default network of the brain The regions of the brain that are most active at rest.
dendrites A structural feature of a neuron that acts like antennas to receive signals from other nearby neurons.
diffusion tensor imaging (DTI) The measurement of the diffusion of water molecules in tissue in order to study connections of neural pathways in the brain.
dopamine A neurotransmitter associated with higher- level cognitive functioning.
dopaminergic system Neuronal systems that use dopa- mine as their major neurotransmitter.
executive functions Include the ability to make and carry out plans, switch between tasks, and maintain attention and focus.
free radicals Substances that can damage cells, includ- ing brain cells, and play a role in cancer and other diseases as we grow older.
functional neuroimaging Provides an indication of brain activity but not high anatomical detail.
HAROLD model A model that explains the empirical findings of reduced lateralization in prefrontal lobe activity in older adults (that is, the reduced ability of older adults to separate cognitive processing in differ- ent parts of the prefrontal cortex).
hippocampus Located in the medial-temporal lobe, this part of the brain plays a major role in memory and learning.
limbic system A set of brain structures involved with emotion, motivation, and long-term memory, among other functions.
neuro correlational approach An approach that attempts to relate measures of cognitive performance to measures of brain structure or functioning.
neural stem cells Cells that persist in the adult brain and can generate new neurons throughout the life span.
neuroanatomy The study of the structure of the brain.
neurofibers Structures in the neuron that carry infor- mation inside the neuron from the dendrites to the terminal branches.
neuroimaging A set of techniques in which pictures of the brain are taken in various ways to provide understanding of both normal and abnormal cognitive aging.
neurons A brain cell.
neuropsychological approach Compares brain func- tioning of healthy older adults with adults displaying various pathological disorders in the brain.
neuroscience The study of the brain.
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56 CHAPTER 2
neurotransmitters Chemicals that carry information signals between neurons across the synapse.
Parieto-Frontal Integration Theory (P-FIT) A theory that proposes that intelligence comes from a distrib- uted and integrated network of neurons in the pari- etal and frontal areas of the brain.
plasticity Involves the interaction between the brain and the environment and is mostly used to describe the effects of experience on the structure and func- tions of the neural system.
positivity effect When an individual remembers more positive information relative to negative information.
prefrontal cortex Part of the frontal lobe that is involved in executive functioning.
Scaffolding Theory of Cognitive Aging (STAC) A model based on the idea that age-related changes in one’s ability to function reflect a life-long process of compensating for cognitive decline by recruiting additional brain areas.
structural neuroimaging A set of techniques that provides highly detailed images of anatomical features in the brain.
synapse The gap between neurons across which neurotransmitters travel.
terminal branches The endpoints in a neuron that help transmit signals across the synapse.
White matter Neurons that are covered by myelin that serve to transmit information from one part of the cerebral cortex to another or from the cerebral cortex to other parts of the brain.
white matter hyperintensities (WMH) Abnormalities in the brain often found in older adults; correlated with cognitive decline.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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Physical Changes
3.1 WHY DO WE AGE? BIOLOGICAL THEORIES OF AGING Discovering Development: Why Do Most People Think We Age? • Rate-of- Living Theories • Cellular Theories • Programmed-Cell-Death Theories • Implications of the Developmental Forces
3.2 APPEARANCE AND MOBILITY Changes in Skin, Hair, and Voice • Changes in Body Build • Changes in Mobility • Psychological Implications
3.3 SENSORY SYSTEMS Vision • Hearing • Somesthesia and Balance • How Do We Know?: Preventing Falls through Tai Chi • Taste and Smell
3.4 VITAL FUNCTIONS Cardiovascular System • Respiratory System
3.5 THE REPRODUCTIVE SYSTEM Female Reproductive System • Current Controversies: Menopausal Hormone Therapy • Male Reproductive System • Psychological Implications
3.6 THE AUTONOMIC NERVOUS SYSTEM Autonomic Nervous System • Psychological Implications SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 3
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58 CHAPTER 3
The Summer Olympics held in Beijing in 2008 were special for many reasons. Among the most important were accomplishments and milestones in swimming. Michael Phelps set the record for most gold medals won in a single Olympics ( 8 ) and overall ( 14 ). At age 23 , he had reached the highest level of performance for a male swimmer. Phelps epitomized the fact that most world-class amateur and professional athletes reach their peak in their twenties. Indeed, his per- formance declined at the London Games in 2012, at which he won only four gold.
Then there are people who rewrite our beliefs about athletic performance. In Beijing, Dara Torres was competing in her fifth Olympics. As we noted in Chapter 1 , she became, at age 41 , the oldest
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swimmer ever to win an Olympic medal (she won three silver medals), and one of only a few who have won medals in five different Olympic games. Middle-aged adults everywhere were thrilled that someone who traditionally would have been writ- ten off as too old defeated women less than half her age.
Our beliefs about physical performance are changing. To be sure, athletic success is a combi- nation of years of intense practice and excellent genes. But before Beijing, no one would have thought that a middle-aged woman could com- pete at that level. Before London, few thought the overall Olympic record for gold and for total med- als could be broken.
Phelps and Torres represent the best. What about the rest of us? In this chapter, we will dis- cover how physical abilities typically change across adulthood. What makes Phelps and Torres (and other world-class amateur and professional ath- letes) different is that because they stay in great physical condition, the normative changes tend to happen more slowly.
3.1 Why Do We Age? Biological Theories of Aging LEARNING OBJECTIVES
How do rate-of-living theories explain aging? What are the major hypotheses in cellular theories
of aging? How do programmed-cell-death theories propose
that we age? How do the basic developmental forces interact in
biological and physiological aging?
Before he started selling his Lean Mean Grilling Machine, George Foreman was a champion boxer. In fact, at age 44 he became, the oldest boxer ever to win the heavyweight championship. Foreman’s success in the boxing ring came after a 10 -year period when he did not fight and despite the belief that his career was finished.
Why is it that some people, like George Foreman and Dara Torres, manage to stay competitive in their sports into middle age and others of us experience sig- nificant physical decline? For that matter, why do we age at all? After all, some creatures, such as lobsters, do not age as humans do. (As far as scientists can tell,
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PHYSICAL CHANGES 59
lobsters never show measurable signs of aging, such as changes in metabolism or declines in strength or health.) For millennia, scientists and philosophers have pondered the question of why people grow old and die. Their answers have spurred researchers to create a collection of theories based on basic bio- logical and physiological processes. The search has included many hypotheses, such as metabolic rates and brain sizes, that haven’t proved accurate. But as scientists continue unlocking the keys to our genetic code, hope is rising that we may eventually have an answer. To date, though, none of the more than 300 existing theories provides a complete explanation of all the normative changes humans experience (Vintil- dea & Miguel, 2007).
Before we explore some of the partial explana- tions from scientific research, complete the Discov- ering Development exercise. Compare your results for this exercise with some of the theories described next. What similarities and differences did you uncover?
a creature’s metabolism is related to how long it lives (Barzilai, Huffman, Muzumdar, & Bartke, 2012).
Several changes in the way that hormones are pro- duced and used in the human body have been associ- ated with aging, but none have provided a definitive explanation. Although some research indicates that significantly reducing the number of calories animals and people eat may increase longevity, research focus- ing on nonhuman primates shows that longer lives do not always result from restricting calories. Further- more, the quality of life that would result for people on such a diet raises questions about how good a strat- egy calorie restriction is (Barzilai et al., 2012). That’s because the caloric restrictions in this research tend to be extreme. Extrapolated to people, the restrictions could well cause a drop in humans’ ability to engage in the kinds of activities we would consider important for a high quality of life.
Cellular Theories A second family of ideas points to causes of aging at the cellular level. One notion focuses on the number of times cells can divide, which presumably limits the life span of a complex organism. Cells grown in labo- ratory culture dishes undergo only a fixed number of divisions before dying, with the number of possible divisions dropping depending on the age of the donor organism; this phenomenon is called the Hayflick limit, after its discoverer, Leonard Hayflick (Hayflick, 1996). For example, cells from human fetal tissue are capable of 40 to 60 divisions; cells from a human adult are capable of only about 20 .
What causes cells to limit their number of divi- sions? Evidence suggests that the tips of the chromo- somes, called telomeres, play a major role in aging by adjusting the cell’s response to stress and growth stimulation based on cell divisions and DNA damage (Lin, Epel, & Blackburn, 2012). Healthy, normal telo- meres help regulate the cell division and reproduc- tion process.
An enzyme called telomerase is needed in DNA replication to fully reproduce the telomeres when cells divide. But telomerase normally is not present in somatic cells, so with each replication the telomeres become shorter. Eventually, the chromosomes become unstable and cannot replicate because the telomeres become too short.
DISCOVERING DEVELOPMENT: WHY DO MOST PEOPLE THINK WE AGE? What does the average person believe about how and why we age physiologically? To find out, list the various organ and body systems discussed in this chapter. Ask some people of different ages two sets of questions. First, ask them what they think happens to each system as people grow older. Then ask them what they think causes these changes. Compile the results from your interviews, and compare them with what you discover in this chapter. To what extent were your interviewees correct in their descriptions? Where were they off base? Does any of the misin- formation match up with the stereotypes of aging we considered in Chapter 1 ? Why do you think this might be the case? How accurate are people in describing aging?
Rate-of-Living Theories One theory of aging that makes apparent common sense postulates that organisms have only so much energy to expend in a lifetime. (Couch potatoes might like this theory, and may use it as a reason why they are not physically active.) The basic idea is that the rate of
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60 CHAPTER 3
Some researchers believe that in some cases cancer cells proliferate so quickly because telomeres are not able to regulate cell growth and reproduction (Lin et al., 2012; Londoño-Vallejo, 2008). Current thinking is that one effective cancer treatment may involve target- ing telomerase (Harley, 2008). Other research indi- cating the telomeres can be lengthened is promising (Epel, 2012).
Chronic stress may accelerate the changes that occur in telomeres, and thereby shorten one’s life span (O’Donovan, Tomiyama, Lin, Puterman, Adler, Kemeny et al., 2012). Research also shows that mod- erate levels of exercise may slow the rate at which telomeres shorten, which may help slow the aging pro- cess itself (Savela, Saijonmaa, Strandberg, Koistinen, Strandberg, Tilvis et al., 2013).
A second cellular theory is based on a process called cross-linking, in which certain proteins in human cells interact randomly and produce molecules that are linked in such a way as to make the body stiffer (Cavanaugh, 1999b). The proteins in question, which make up roughly one-third of the protein in the body, are called collagen. Collagen in soft body tissue acts much like reinforcing rods in concrete. The more cross-links there are, the stiffer the tissue. For example, leather tanning involves using chemicals that create many cross-links to make the leather stiff enough for use in shoes and other products. As we age, the number of cross-links increases. This process may explain why muscles, such as the heart, and arteries become stiffer with age. However, few scientific data demonstrate that cross-linking impedes metabolic processes or causes the formation of faulty molecules that would constitute a fundamental cause of aging (Hayflick, 1998). Thus, even though cross-linking occurs, it probably is not an adequate explanation of aging.
A third type of cellular theory proposes that aging is caused by unstable molecules called free radicals, which are highly reactive chemicals produced ran- domly in normal metabolism (Dutta, Calvani, Berna- bei, Leeuwenburgh, & Marzetti, 2012). When these free radicals interact with nearby molecules, prob- lems may result. For example, free radicals may cause cell damage to the heart by changing the oxygen lev- els in cells.
The most important evidence that free radi- cals may be involved in aging comes from research
with substances that prevent the development of free radicals in the first place. These substances, called antioxidants, prevent oxygen from combining with susceptible molecules to form free radicals. Com- mon antioxidants include vitamins A, C, and E, and coenzyme Q. A growing body of evidence shows that ingesting antioxidants postpones the appearance of age-related diseases such as cancer, cardiovascular disease, and immune system dysfunction (Dutta et al., 2012; Lu & Finkel, 2008), but there is no direct evidence yet that eating a diet high in antioxidants actually increases the life span (Berger, Lunkenbein, Ströhle, & Hahn, 2012).
Programmed-Cell-Death Theories What if aging were programmed into our genetic code? This possibility seems more likely as the explosion of knowledge about human genetics continues to unlock the secrets of our genetic code. Even when cell death appears random, researchers believe that such losses may be part of a master genetic program that under- lies the aging process (Freitas & de Magalhães, 2011; Mackenzie, 2012). Programmed cell death appears to be a function of physiological processes, the innate ability of cells to self-destruct, and the ability of dying cells to trigger key processes in other cells. At present, we do not know how this self-destruct program is acti- vated, nor do we understand how it works. Neverthe- less, there is increasing evidence that many diseases associated with aging (such as Alzheimer’s disease) have genetic aspects.
It is quite possible that the other explanations we have considered in this section and the changes we examine throughout this text are the result of a genetic program. We will consider many diseases through- out the text that have known genetic bases, such as Alzheimer’s disease. As genetics research continues, it is likely that we will have some exciting answers to the question, Why do we age?
Implications of the Developmental Forces Although scientists do not yet have one unified the- ory of biological and physiological aging, the picture is becoming clearer. We know that there are genetic components, that the body’s chemistry lab sometimes produces incorrect products, and that errors occur in the operation and replication of DNA (Freitas & de
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PHYSICAL CHANGES 61
Magalhães, 2011). From the perspective of the basic developmental forces, the biological theories provide ways to describe the biological forces. As we examine specific body systems in this chapter and health-related processes in Chapter 4 , we will begin to integrate the biological forces with the psychological, sociocultural, and life-cycle forces. In those discussions, notice how changes in body systems and diseases are influenced by these other factors.
The implication of this dynamic, interactive pro- cess is that the diagnosis and treatment of health- related concerns must also include many perspectives. It is not enough to have your physical functioning checked to establish whether you are healthy. Rather, you need not only a typical bodily physical but also a checkup of psychological and sociocultural function- ing. Finally, the results of all these examinations must be placed in the context of the overall life span.
So, a unified theory of aging would have to account for a wide array of changes relating not only to biologi- cal forces but to other forces as well. Perhaps then we’ll discover why George Foreman was still successful in the boxing ring and Dara Torres was winning in the pool when most of their peers were watching them on television.
Or we just might discover how to reverse or stop aging. The business of “antiaging medicine,” prod- ucts designed to stop or prevent aging, is booming. Although most researchers who specialize in study- ing the fundamental mechanisms of aging largely dis- miss such efforts, not all do. For example, research on the Chinese herb Sanchi ( Panax notoginsengs ) shows promise in reducing wrinkles (Rattan, Kryzch, Schne- bert, Perrier, & Nizard, 2013). Healthy behaviors that delay the effects of aging are legitimate activities that have a research foundation; whether they should be called “antiaging” is another matter (Palmore, 2007). Exercise has been shown to delay many aspects of aging; cosmetic surgery aimed at making someone look younger does not, and is likely more related to aging stereotypes than healthy lifestyles.
There are three general research-based approaches to the work aimed at slowing or reversing aging. First, the goal is to delay the chronic illnesses of old age. Second, there is research aimed at slowing the funda- mental processes of aging so that the average life span is increased to over 110 years (from roughly 78 now).
Third, some researchers seek to arrest or even reverse aging, perhaps by removing the damage inevitably caused by metabolic processes.
Research separating healthy behaviors from age denials is key (Palmore, 2007). Legitimate research sponsored by such agencies as the National Institutes of Health becomes confused with counterfeit antiag- ing interventions. If the legitimate research unlocks the secrets of aging, then a serious public discussion is needed to prepare society for the implications of a pos- sible significant lengthening of the life span.
Adult Development in Action If you were a geriatric nurse, what advice would you give to your patients about living longer based on existing biological theories of aging?
3.2 Appearance and Mobility LEARNING OBJECTIVES
How do our skin, hair, and voices change with age?
What happens to our body build with age? What age-related changes occur in our ability to
move around?
By all accounts, Kristina is extremely successful. She was a famous model in her late teens and 20 s, and by the time she was 36 she had learned enough about the busi- ness to start her own multinational modeling agency. The other day Kristina was very upset when she looked in the mirror and saw a wrinkle. “Oh no,” she exclaimed, “I can’t be getting wrinkles! What am I going to do?”
Kristina’s experience isn’t unique. We all see the outward signs of aging first in the mirror: gray hair, wrinkled skin, and an expanding waistline or hips. These changes occur gradually and at different rates; some of us experience all the changes in young adult- hood, whereas others don’t have them until late middle or old age. How we perceive the person staring back at us in the mirror says a great deal about how we feel about aging; positive feelings about the signs of aging are related to positive self-esteem.
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62 CHAPTER 3
How easily we move our changing bodies in the physical environment is also a major component of adaptation and well-being in adulthood. If we can- not get around, we must depend on others, which lowers our self-esteem and sense of competence. Having a body that moves effectively also lets us enjoy physical activities such as walking, swimming, and skiing.
Changes in Skin, Hair, and Voice When we, like Kristina, see the first visible signs of aging, it makes no difference that these changes are universal and inevitable. Nor does it matter that our wrinkles are caused by a combination of changes in the structure of the skin and its connective and sup- portive tissue and the cumulative effects of exposure to sunlight. As normal as the loss of hair pigmentation is, we may still want to hide the gray (Aldwin & Gilmer, 2013). What matters on that day is that we have seen our first wrinkle and gray hair.
Changes in the Skin. Why does our skin wrinkle? Wrinkling is actually a complex, four-step process (Robert, Labat-Robert, & Robert, 2012). First, the outer layer of skin becomes thinner through cell loss, causing the skin to become more fragile. Second, the collagen fibers that make up the connective tissue lose much of their flexibility, making the skin less able to regain its shape after a pinch. Third, elastin fibers in the middle layer of skin lose their ability to keep the skin stretched out, resulting in sagging. Finally, the underlying layer of fat, which helps provide padding to smooth out the contours, diminishes.
It may surprise you to know that how quickly your face ages is largely under your control. Two major environmental causes of wrinkles are exposure to ultraviolet rays from the sun, which breaks down the skin’s connective tissue, and smoking, which restricts the flow of blood to the skin around the lips (Mayo Clinic, 2012a). Using sunscreens and sunblocks prop- erly and limiting your exposure to sunlight, as well as quitting smoking, may slow the development of wrinkles. The message is clear: Young adults who are dedicated sun-worshippers or are smokers eventually pay a high price.
Older adults’ skin is naturally thinner and drier, giving it a leathery texture, making it less effective at
regulating heat or cold, and making it more susceptible to cuts, bruises, and blisters. To counteract these prob- lems, people should use skin moisturizers, vitamin E, and facial massages (Mayo Clinic, 2012a; Robert et al., 2012). The coloring of light-skinned people undergoes additional changes with age. The number of pigment- containing cells in the outer layer decreases, and those that remain have less pigment, resulting in lighter skin. In addition, age spots (areas of dark pigmenta- tion that look like freckles) and moles (pigmented outgrowths) appear more often. Some of the blood vessels in the skin may become dilated and create small, irregular red lines. Varicose veins may appear as knotty, bluish irregularities in blood vessels, especially on the legs (Aldwin & Gilmer, 2004; Weiss, Munavalli, Choudhary, Leiva, & Nouri, 2012).
Changes in the Hair. Gradual thinning and gray- ing of the hair of both men and women occur inevi- tably with age, although there are large individual
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PHYSICAL CHANGES 63
differences in the rate of these changes. Hair loss is caused by destruction of the germ centers that pro- duce the hair follicles, whereas graying results from a cessation of pigment production. Men usually do not lose facial hair as they age; you probably have seen many balding men with thick, bushy beards. In addition, men often develop bushy eyebrows and hair growth inside the ears. In contrast, women often develop patches of hair on the face, especially on the chin (Aldwin & Gilmer, 2004). This hair growth is related to the hormonal changes of the climacteric, discussed later in this chapter.
Changes in the Voice. The next time you’re in a crowd of people of different ages, close your eyes and listen to the way they sound. You probably will be fairly accurate in guessing how old the speakers are just from the quality of the voices you hear. Younger adults’ voices tend to be full and resonant, whereas older adults’ voices tend to be thinner or weaker. Age- related changes in one’s voice include lowering of pitch, increased breathlessness and trembling, slower and less precise pronunciation, and decreased volume. A longitudinal study of Japanese adults revealed that women have more changes in their fundamental fre- quency, and shimmer (i.e., frequent change from soft to loud volume) and glottal noise is characteristic of older voices (Kasuya et al., 2008). Some researchers report that these changes are due to changes in the larynx (voice box), the respiratory system, and the muscles controlling speech. However, other research- ers contend that these changes result from poor health and are not part of normal aging.
Changes in Body Build If you have been around the same older people, such as your grandparents, for many years, you undoubtedly have noticed that the way their bodies look changed over time. Two changes are especially visible: a decrease in height and fluctuations in weight. Height remains fairly stable until the 50 s , but between the mid- 50 s and mid- 70 s men lose about 1 inch and women lose about 2 inches (Havaldar, Pilli, & Putti, 2012). This height loss usually is caused by compression of the spine from loss of bone strength, changes in the discs between the vertebrae in the spine, and changes in posture. Impor- tantly, height loss of more than 3 cm is associated
with increased risk of dying from cardiovascular and respiratory diseases (Masunari, Fujiwara, Kasagi, Taka- hashi, Yamada, & Nakamura, 2012). We consider some specific aspects of changes in bone structure a bit later.
Weight gain in middle age followed by weight loss in later life is common. Typically, people gain weight between their 20 s and their mid- 50 s but lose weight throughout old age. In part, the weight gain is caused by changes in body metabolism, which tends to slow down, and reduced levels of exercise, which in turn reduces the number of calories needed daily. Unfor- tunately, many people do not adjust their food intake to match these changes. The result is often tighter- fitting clothes. For men, this weight gain tends to be around the abdomen, creating middle-aged bulge. For women, this weight gain tends to be around the hips, giving women the familiar “pear-shaped” figure. By late life, though, the body loses both muscle and bone, which weigh more than fat, in addition to some fat, resulting in weight loss (Yang, Bishai, & Harman, 2008). Research on the relationships among body weight, health, and survival shows that older adults who have normal body weight at age 65 have lon- ger life expectancy and lower rates of disability than 65 -year-olds in other weight categories. Keeping your weight in the normal range for your height, then, may help you live longer.
Changes in Mobility Being able to get around on one’s own is an important part of remaining independent. As you will see, we all experience some normative changes that can affect our ability to remain mobile, but most of these changes do not inevitably result in serious limitations.
Muscles and Balance. Although the amount of mus- cle tissue in our bodies declines with age, this loss is hardly noticeable in terms of strength and endurance; even at age 70 the loss is no more than 20 %. After that, however, the rate of change increases. By age 80 the loss in strength is up to 40 %, and it appears to be more severe in the legs than in the arms and hands. How- ever, some people retain their strength well into old age (Seene, Kaasik, & Riso, 2012). Research evidence suggests that muscle endurance also diminishes with age but at a slower rate. Men and women show no dif- ferences in the rate of muscle change.
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64 CHAPTER 3
This loss of muscle strength is especially impor- tant in the lower body (El Haber et al., 2008). As lower body strength declines, the likelihood of balance prob- lems and falls increases, as do problems with walking. Exercise may help delay these changes.
Bones. You have probably seen commercials and advertise ments aimed mostly at women for products that help maintain bone mass. If you surmise that such products reflect a serious and real health con- cern, you are correct. Normal aging is accompanied by the loss of bone tissue throughout the body. Bone loss begins in the late 30 s , accelerates in the 50 s (par- ticularly in women), and slows by the 70 s (Haval- dar et al., 2012). The gender difference in bone loss is important. Once the process begins, women lose bone mass approximately twice as fast as men. The difference results from two factors. First, women have less bone mass than men in young adulthood, meaning that they start out with less ability to with- stand bone loss before it causes problems. Second, the depletion of estrogen after menopause speeds up bone loss.
What happens to aging bones? The process involves a loss of bone mass inside the bone, which makes bones more hollow. In addition, bones tend to become porous. The changes result from body weight, genetics, and lifestyle factors such as smok- ing, alcohol use, and diet (Havaldar et al., 2012). All
these bone changes cause an age-related increase in the likelihood of fractures, because hollow, porous bones are easier to break. Furthermore, broken bones in older people present more serious problems than in younger adults, because they are more likely to be clean fractures that are difficult to heal. Bones of younger adults fracture in such a way that there are many cracks and splinters to aid in healing. This is analogous to the difference between breaking a young, green tree branch (which is harder to do) and snapping an old, dry twig.
Women are especially susceptible to severe bone degeneration, a disease called osteoporosis, in which the loss of bone mass and increased porosity create bones that resemble laced honeycombs. You can see the result in Figure 3.1 . Eventually, people with osteoporosis tend to develop a distinct curvature in their spines, as shown in Figure 3.2 .
Osteoporosis is the leading cause of broken bones in older women (NIHSeniorHealth, 2011a). Although it is most common in older adults, osteoporosis can occur in people in their 50s.
Osteoporosis is more common in women than men, largely because women have less bone mass in general, because some girls and women do not con- sume enough dietary calcium to build strong bones when they are younger (i.e., build bone mass), and because the decrease in estrogen following menopause greatly accelerates bone loss.
Osteoporotic bone tissue Normal bone tissue
Figure 3.1 Osteoporotic and normal bone structures. Notice how much mass the osteoporotic bone has lost. © 2015 Cengage Learning
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PHYSICAL CHANGES 65
Osteoporosis is caused in part by having low bone mass at skeletal maturity (the point at which your bones reach peak development), deficiencies in calcium and vitamin D, estrogen depletion, and lack of weight-bearing exercise that builds up bone mass. Other risk factors include smoking; high-protein diets; and excessive intake of alcohol, caffeine, and sodium. Women who are being treated for asthma, cancer, rheumatoid arthritis, thyroid problems, or epilepsy are also at increased risk because the medications used can lead to the loss of bone mass.
NIHSeniorHealth (2011b) recommends getting enough vitamin D and dietary calcium as ways to pre- vent osteoporosis. There is evidence that calcium sup- plements after menopause may slow the rate of bone
loss and delay the onset of osteoporosis, but benefits appear to be greater when the supplements are pro- vided before menopause. People should consume foods (such as milk or broccoli) that are high in calcium and should also take calcium supplements if necessary. Recommended calcium intake for men and women of various ages are shown in Table 3.1 . Data clearly show that metabolizing vitamin D directly affects rates of osteoporosis; however, whether supplementary dietary vitamin D retards bone loss is less certain (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2008b).
In terms of medication interventions, bisphos- phonates are the most commonly used and are highly effective, but can have side effects if used over
Figure 3.2 Changes in the curvature of the spine as a result of osteoporosis. These changes create the stooping posture common to older people with advanced osteoporosis. Source: Reprinted with permission from Ebersole, P., & Hess, P., Toward Healthy Aging, 5e, (p. 395). Copyright © 1998 Mosby St. Louis: with permission from Elsevier.
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66 CHAPTER 3
a long period of time (Salari & Abdollahi, 2012). Fosamax, Actonel, and Boniva are three common examples of this family of medications. Bisphospho- nates slow the bone breakdown process by helping to maintain bone density during menopause. Research indicates that using bisphosphonates for up to five years appears relatively safe if followed by stopping the medication (called a “drug holiday”); there is evidence for protective effects lasting up to five years more.
Lowering the risk of osteoporosis involves dietary, medication, and activity approaches (NIHSeniorHealth, 2011b). Some evidence also supports the view that taking supplemental magnesium, zinc, vitamin K, and special forms of fluoride may be effective. Estrogen replace- ment is effective in preventing women’s bone loss after menopause but is controversial because of potential side effects (as discussed later). There is also evidence that regular weight-bearing exercise (e.g., weight lifting, jog- ging, or other exercise that forces you to work against gravity) is beneficial.
Joints. Many middle-aged and older adults complain of aching joints. They have good reason. Beginning in the 20 s , the protective cartilage in joints shows signs of deterioration, such as thinning and becoming cracked and frayed. Two types of arthritis can result: osteoar- thritis and rheumatoid arthritis. These diseases are illustrated in Figure 3.3 .
Over time the bones underneath the cartilage become damaged, which can result in osteoarthritis, a disease marked by gradual onset and progression of pain and disability, with minor signs of inflammation (National Institute of Arthritis and Musculoskel- etal and Skin Diseases, 2010a). The disease usually becomes noticeable in late middle age or early old age, and it is especially common in people whose joints are subjected to routine overuse and abuse, such as athletes and manual laborers. Thus osteoarthritis is a wear-and-tear disease. Pain typically is worse when the joint is used, but skin redness, heat, and swelling are minimal or absent. Osteoarthritis usually affects the hands, spine, hips, and knees, sparing the wrists, elbows, shoulders, and ankles. Effective management approaches consist mainly of certain steroids and anti- inflammatory drugs, rest, nonstressful exercises that focus on range of motion, diet, and a variety of homeo- pathic remedies.
A second form of arthritis is rheumatoid arthritis, a more destructive disease of the joints that also devel- ops slowly and typically affects different joints and causes other types of pain than osteoarthritis (National Institute of Arthritis and Musculoskeletal and Skin Diseases., 2009). Most often, a pattern of morning stiffness and aching develops in the fingers, wrists, and ankles on both sides of the body. Joints appear swollen.
The typical therapy for rheumatoid arthritis consists of aspirin or other nonsteroidal anti-inflammatory drugs, such as Advil or Aleve. Newer treatments include disease-modifying anti-rheumatic drugs (DMARDs) (such as hydroxycholorquine and methotrexate) that limit the damage occurring in the joints, and TNF- alpha inhibitors that act as an anti-inflammatory agent and have been shown to stop the disease’s progression in some patients. Rest and passive range-of-motion exer- cises are also helpful.
Contrary to popular belief, rheumatoid arthritis is not contagious, hereditary, or self-induced by any
Table 3.1
Recommended Calcium and Vitamin D Intakes
AGE CALCIUM
(MILLIGRAMS)
VITAMIN D (INTERNATIONAL
UNITS)
Infants
Birth to 6 months 200 400
6 months to 1 year 260 400
Children and Young Adults
1 to 3 years 700 600
4 to 8 years 1,000 600
9 to 13 years 1,300 600
14 to 18 years 1,300 600
Adult Women and Men
19 to 30 years 1,000 600
31 to 50 years 1,000 600
51 - to 70 -year-old males
1,000 600
51 - to 70 -year-old females
1,200 600
Over 70 years 1,200 800
Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2010d .
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PHYSICAL CHANGES 67
known diet, habit, job, or exposure. Interestingly, the symptoms often come and go in repeating patterns (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2009). Although apparently not directly inherited, family history of rheumatoid arthri- tis plays a role because researchers think that you can inherit a predisposition for the disease.
Surgical interventions may be an option if medica- tions do not provide relief. For example, arthroplasty, or the total replacement of joints damaged by arthritis, continues to improve as new materials help artificial joints last longer. When joints become inflamed, sur- geons may be able to remove the affected tissue. Or in some cases cartilage may be transplanted into a dam- aged joint. These latter two approaches help patients avoid full joint replacement, generally viewed as the method of last resort.
Comparisons among osteoporosis, osteoarthritis, and rheumatoid arthritis can be seen in Table 3.2 .
Psychological Implications The appearance of wrinkles, gray hair, fat, and the like can have major effects on a person’s self-concept (Aldwin & Gilmer, 2004) and reflect ageism in society
(Clarke & Griffin, 2008). Middle-aged adults may still think of themselves as productive members of soci- ety and rebel against being made invisible. Because U.S. society places high value on looking young, middle-aged and older adults, especially women, may be regarded as inferior on a number of dimensions, including intellectual ability. Consequently, women report engaging in “beauty work” (dyeing their hair, cosmetic surgery, and the like) in order to remain visible in society. In contrast, middle-aged men with some gray hair often are considered distinguished, more experienced, and more knowledgeable than their younger counterparts.
Given the social stereotypes we examined in Chapter 1 , many women (and increasingly, some men) use any available means to compensate for these changes. Some age-related changes in facial appear- ance can be disguised with cosmetics. Hair dyes can restore color. Surgical procedures such as face-lifts can tighten sagging and wrinkled skin. But even plas- tic surgery only delays the inevitable; at some point everyone takes on a distinctly old appearance.
Losses in strength and endurance in old age have much the same psychological effects as changes in
Bone
Fibrous sheath
Synovial membrane
Cartilage
NORMAL JOINT
Bone loss
Thickened synovial
membrane
Worn cartilage
Bone spurs
Synovial changes
Worn cartilage
RHEUMATOID ARTHRITIS OSTEOARTHRITIS
Figure 3.3 Rheumatoid arthritis versus osteoarthritis. Osteoarthritis, the most common form of arthritis, involves the wearing away of the cartilage that caps the bones in your joints. With rheumatoid arthritis, the synovial membrane that protects and lubricates joints becomes inflamed, causing pain and swelling. Joint erosion may follow. Adapted from the MayoClinic.com article, “Arthritis” (http://www.mayoclinic.com/health/arthritis/DS01122)
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68 CHAPTER 3
appearance (Aldwin & Gilmer, 2004). In particular, these changes tell the person that he or she is not as capable of adapting effectively to the environment. Loss of muscle coordination (which may lead to walk- ing more slowly, for example) may not be inevitable, but it can prove embarrassing and stressful. Exercise and resistance training can improve muscle strength, even up to age 90 , and may also reduce the odds of getting dementia (Andel et al., 2008). Interestingly, the rate of improvement does not seem to differ with age; older adults get stronger at the same rate as younger adults.
The changes in the joints, especially in arthri- tis, have profound psychological effects (Aldwin & Gilmer, 2004). These changes can severely limit
movement, thereby reducing independence and the ability to complete normal daily routines. More- over, joint pain is very difficult to ignore or dis- guise, unlike changes in appearance. Consequently, the person who can use cosmetics to hide changes in appearance cannot use the same approach to deal with constant pain in the joints. Older adults who suffer bone fractures face several other consequences in addition to discomfort. For example, a hip fracture may force hospitalization or even a stay in a nursing home. For all fractures, the recovery period is much longer than for a younger adult. In addition, older people who witness friends or relatives struggling during rehabilitation may reduce their own activities as a precaution.
Table 3.2
Similarities and Differences Among Osteoporosis, Osteoarthritis, and Rheumatoid Arthritis
OSTEOPOROSIS OSTEOARTHRITIS RHEUMATOID
ARTHRITIS
Risk Factors
Age-related x x
Menopause x
Family history x x x
Use of certain medications such as glucocorti- coids or seizure medications x
Calcium deficiency or inadequate vitamin D x
Inactivity x
Overuse of joints x
Smoking x
Excessive alcohol x
Anorexia nervosa x
Excessive weight x
Physical Effects
Affects entire skeleton x
Affects joints x x
Is an autoimmune disease x
Bony spurs x x
Enlarged or malformed joints x x
Height loss x
Sources: National Institute of Arthritis and Musculoskeletal and Skin Diseases (2006), http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_ Behaviors/osteoporosis_arthritis.asp .
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PHYSICAL CHANGES 69
3.3 Sensory Systems LEARNING OBJECTIVES
What age-related changes happen in vision? How does hearing change as people age? What age-related changes occur in people’s
senses of touch and balance? What happens to taste and smell with increasing
age?
Bertha has attended Sunday services in her local AME (African Methodist Episcopal) church for 82 years. Over the past few years, though, she has experienced greater difficulty in keeping her balance as she walks down the steps from her row house to the sidewalk. Bertha is notic- ing that her balance problems occur even when she is walking on level ground. Bertha is concerned that she will have to stop attending her beloved church because she is afraid of falling and breaking a bone.
You have probably seen people like Bertha walk- ing slowly and tentatively along the sidewalk. Why do older people have these problems more often? If you said it is because the sensory system directly related to maintaining balance, the vestibular system, and mus- cle strength decline with age, you would only be partly correct. It turns out that keeping one’s balance is a complex process in which we integrate input from sev- eral sources, such as vision and touch, as well as bones and joints. In this section we examine the changes that occur in our sensory systems. These changes challenge our ability to interact with the world and communicate with others.
Vision Have you ever watched middle-aged people try to read something that is right in front of them? If they do not already wear glasses or contact lenses, they typi- cally move the material farther away so that they can
see it clearly. This change in vision is one of the first noticeable signs of aging, along with the wrinkles and gray hair we considered earlier. Because we rely exten- sively on sight in almost every aspect of our waking life, its normative, age-related changes have profound and pervasive effects on people’s everyday lives, espe- cially feelings of sadness and loss of enjoyment of life (Mojon-Azzi, Sousa-Poza, & Mojon, 2008).
How does eyesight change with age? The major changes are best understood by grouping them into two classes: changes in the structures of the eye, which begin in the 40 s , and changes in the retina, which begin in the 50 s (Mojon-Azzi et al., 2008).
Structural Changes in the Eye. Two major kinds of age-related structural changes occur in the eye. One is a decrease in the amount of light that passes through the eye, resulting in the need for more light to do tasks such as reading (Andersen, 2012). As you might sus- pect, this change is one reason why older adults do not see as well in the dark, which may account in part for their reluctance to go places at night. One possible logical response to the need for more light would be to increase illumination levels in general. However, this solution does not work in all situations because we also become increasingly sensitive to glare. In addition, our ability to adjust to changes in illumination, called adaptation, declines. Going from outside into a dark- ened movie theater involves dark adaptation; going back outside involves light adaptation. Research indi- cates that the time it takes for both types of adaptation increases with age (Charman, 2008). These changes are especially important for older drivers, who have more difficulty seeing after confronting the headlights of an oncoming car.
The other key structural changes involve the lens (Andersen, 2012; Charman, 2008). As we grow older, the lens becomes more yellow, causing poorer color dis- crimination in the green–blue–violet end of the spec- trum. Also, the lens’s ability to adjust and focus declines as the muscles around it stiffen. This is what causes dif- ficulty in seeing close objects clearly ( called presbyopia ), necessitating either longer arms or corrective lenses . To complicate matters further, the time our eyes need to change focus from near to far (or vice versa) increases. This also poses a major problem in driving. Because
Adult Development in Action If you were a personal exercise trainer, what regimen would you recommend for your older clients to help them maintain maximum health?
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70 CHAPTER 3
drivers are constantly changing their focus from the instrument panel to other autos and signs on the high- way, older drivers may miss important information because of their slower refocusing time.
Besides these normative structural changes, some people experience diseases caused by abnormal struc- tural changes. First, opaque spots called cataracts may develop on the lens, which limits the amount of light transmitted . Cataracts often are treated by surgical removal and use of corrective lenses. Second, the fluid in the eye may not drain properly, causing very high pres- sure; this condition, called glaucoma, can cause internal damage and loss of vision . Glaucoma, a fairly common disease in middle and late adulthood, is usually treated with eye drops.
Retinal Changes. The second major family of changes in vision result from changes in the retina. The retina lines approximately two-thirds of the interior of the eye. The specialized receptor cells in vision, the rods and the cones, are contained in the retina. They are most densely packed toward the rear and especially at the focal point of vision, a region called the macula. At the center of the macula is the fovea, where incoming light is focused for maximum acuity, as when you are read- ing. With increasing age, the probability of degenera- tion of the macula increases (Ambati & Fowler, 2012). Macular degeneration involves the progressive and irre- versible destruction of receptors from any of a number of causes. This disease results in the loss of the ability to see details; for example, reading is extremely difficult, and television often is reduced to a blur. It is the leading cause of functional blindness in older adults.
A second age-related retinal disease is a by- product of diabetes, a chronic disease described in detail in
Chapter 4 . Diabetes is accompanied by accelerated aging of the arteries, with blindness being one of the more serious side effects. Diabetic retinopathy, as this condi- tion is called, can involve fluid retention in the macula, detachment of the retina, hemorrhage, and aneurysms (Bronson-Castain, Bearse, Neuville, Jonasdottir, King- Hooper, Barez et al., 2012). Because it takes many years to develop, diabetic retinopathy is more common among people who developed diabetes early in life.
The combined effects of the structural changes in the eye create two other types of changes. First, the ability to see detail and to discriminate different visual patterns, called acuity, declines steadily between ages 20 and 60 , with a more rapid decline thereafter. Loss of acuity is especially noticeable at low light levels (Charman, 2008).
Psychological Effects of Visual Changes. Clearly, age-related changes in vision affect every aspect of older adults’ daily lives and their well-being (Mojon- Azzi et al., 2008; Zimdars, Nazroo, & Gjonça, 2012). Imagine the problems people experience performing tasks that most young adults take for granted, such as reading a book, watching television, reading grocery labels, or driving a car. Fortunately, some of the univer- sal changes, such as presbyopia, can be corrected easily through glasses or contacts. Surgery to correct cata- racts is now routine. The diseased lens is removed and an artificial one is inserted in an outpatient procedure that usually lasts about 30 minutes, with little discom- fort. Patients usually resume their normal activities in less than a week and report much improved daily lives.
If you want to provide environmental support for older adults, taking their vision changes into account, you need to think through your intervention strategies carefully. For example, simply making the environ- ment brighter may not be the answer. For increased illumination to be beneficial, surrounding surfaces must not increase glare. Using flat latex paint rather than glossy enamel and avoiding highly polished floors are two ways to make environments “older adult– friendly.” There should be high contrast between the background and operational information on dials and controls, such as on stoves and radios. Older adults may also have trouble seeing some fine facial details which may lead them to decrease their social contacts for fear of not recognizing someone.Older driververe s mmay ay ay mismiss is infonformarmar tiotionn n due to chchangengnges is is in vn vn visiisiion.onon.on. © T
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PHYSICAL CHANGES 71
Visual impairments with age change the relations between certain personality traits and emotion (Wahl, Heyl, & Schilling 2012). For instance, the relationship between extraversion and positive emotions is stronger in people with few or no impairments than in people with impairments. Visual problems also increase vul- nerability to falls because the person may be unable to see hazards in his or her path or to judge distance very well. Thus, part of Bertha’s concern about falling may be caused by changes in her ability to tell where the next step is or to see hazards along the sidewalk.
Hearing Experiencing hearing loss is one of the most well-known normative changes with age (Li-Korotky, 2012). A visit to any housing complex for older adults will easily verify this point; you will quickly notice that television sets and radios are turned up fairly loud in most of the apartments. Yet you don’t have to be old to experience significant hearing problems. When he began to find it difficult to hear what was being said to him, President Bill Clinton obtained two hearing aids. He was 51 years old at the time, and he attributed his hearing loss to too many high school bands and rock concerts when he was young. His situation is far from unique. Loud noise is the enemy of hearing at any age. You probably have seen people who work in noisy environments wearing pro- tective gear on their ears so that they are not exposed to loud noise over extended periods of time.
But you can do serious damage to your hearing with short exposure, too; in 1988, San Francisco punk rock bassist Kathy Peck was performing with her all- female punk band “The Contractions” at the Oakland Coliseum and played so loudly that she had ringing in her ears for 3 days and suffered permanent hearing loss. As a result, she founded Hearing Education and Aware- ness for Rockers (HEAR; http://www.hearnet.com ) shortly thereafter to educate musicians about the need to protect their ears (Noonan, 2005). You don’t need to be at a concert to damage your hearing, either. Using headphones or earbuds, especially at high volume, can cause the same serious damage and should be avoided (Gilliver, Carter, Macoun, Rosen, & Williams, 2012). It is especially easy to cause hearing loss with headphones or earbuds if you wear them while exercising; the increased blood flow to the ear during exercise makes hearing receptors more vulnerable to damage. Because young
adults do not see their music listening behavior as a risk (Gilliver et al., 2012), hearing loss from this and other sources of loud noise is on the rise. The worse news is that hearing loss is also likely to increase among older adults in the future (Agrawal, Platz, & Niparko, 2008).
The cumulative effects of noise and normative age- related changes create the most common age-related hearing problem: reduced sensitivity to high-pitched tones, called presbycusis, which occurs earlier and more severely than the loss of sensitivity to low-pitched tones (Agrawal et al., 2008). Research indicates that by the late 70 s , roughly half of older adults have presbycusis. Men typically have greater loss than women, but this may be because of differential exposure to noisy environments. Hearing loss usually is gradual at first but accelerates during the 40 s , a pattern shown clearly in Figure 3.4 .
Presbycusis results from four types of changes in the inner ear (Punnoose, Lynm, & Golub, 2012): sen- sorineural, consisting of atrophy and degeneration of receptor cells or the auditory nerve, and is permanent; and conductive, consisting of obstruction of or dam- age to the vibrating structures in the outer or middle ear area. Knowing the cause of a person’s presbycusis is important, because the different causes have differ- ent implications for other aspects of hearing (Punnoose et al., 2012). Sensory presbycusis has little effect on other hearing abilities. Neural presbycusis seriously affects the ability to understand speech. Metabolic presbycusis produces severe loss of sensitivity to all pitches. Finally, mechanical presbycusis also produces loss across all pitches, but the loss is greatest for high pitches.
Because hearing plays a major role in social commu- nication, its progressive loss could have an equally impor- tant effect on people’s quality of life (Heyl & Wahl, 2012). Dalton and colleagues (2003) found that people with moderate to severe hearing loss were significantly more likely to have functional impairments with tasks in daily life (e.g., shopping). In addition, they were more likely to have decreased cognitive functioning. Clearly, significant hearing impairment can result in decreased quality of life.
Loss of hearing in later life can also cause numer- ous adverse emotional reactions, such as loss of inde- pendence, social isolation, irritation, paranoia, and depression. Much research indicates hearing loss per se does not cause social maladjustment or emotional disturbance. However, friends and relatives of an older person with undiagnosed or untreated hearing
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72 CHAPTER 3
loss often attribute emotional changes to hearing loss, which strains the quality of interpersonal relationships (Li-Korotky, 2012). Thus, hearing loss may not directly affect older adults’ self-concept or emotions, but it may negatively affect how they feel about interpersonal communication. By understanding hearing loss prob- lems and ways to overcome them, people who have no hearing loss can play a large part in minimizing the effects of hearing loss on the older people in their lives.
Fortunately, many people with hearing loss can be helped through two types of amplification systems and cochlear implants, described in Table 3.3 . Analog hear- ing aids are the most common and least expensive, but they provide the lowest-quality sound. Digital hearing aids include microchips that can be programmed for different hearing situations. Cochlear implants do not amplify sound; rather, a microphone transmits sound to a receiver, which stimulates auditory nerve fibers
0 dB
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Figure 3.4 Gender differences in hearing loss. Notice that the changes in men are greater. Source: J. M. Ordy, K. R. Brizzee, T. Beavers, & P. Medart. “Age differences in the Functional and Structural Organization of the Auditory System in Man,” in J. M. Ordy & K. R. Brizzee (eds.), Sensory Systems and Communication in the Elderly . Copyright © Lippincott, Williams & Wilkins, 1979.
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PHYSICAL CHANGES 73
directly. Although technology continues to improve, none of these devices can duplicate your original equipment, so be kind to your ears.
Somesthesia and Balance Imagine that you are locked in an embrace with a lover right now. Think about how good it feels when you are caressed lovingly, the tingly sensations you get. You can thank your somesthetic system for that; without it, you probably wouldn’t bother. Remember Bertha, the older woman worried about falling? To maintain balance and avoid falls, your somesthetic system integrates a great deal of information about your body position.
Somesthesia. As you’ve probably discovered, a lover’s touch feels different on various parts of your body. That’s because the distribution of touch receptors is not consis- tent throughout the body; the greatest concentrations are in the lips, tongue, and fingertips. Although it takes more pressure with age to feel a touch on the smooth (non- hairy) skin on the hand such as the fingertips (Stevens, 1992), touch sensitivity in the hair-covered parts of the body is maintained into later life (Whitbourne, 1996a).
Older adults often report that they have more trouble regulating body temperature so that they feel comfortable (Guergova & Dufour, 2011). Changes in the perception of temperature are likely caused by aging
of the skin and reduction in the number of temperature receptors, as well as possible changes in the peripheral nerves. These changes are greater in the arms and legs.
Sensations from the skin, internal organs, and joints serve critical functions. They keep us in contact with our environment, help us avoid falling, help us communicate, keep us safe, and factor into our perception of pain. In terms of self-esteem, how well our body is functioning tells us something about how well we are doing. Losing bodily sensations can have major implications; loss of sexual sensitivity and changes in the ability to regulate one’s body temperature affect the quality of life. How a person views these changes is critical for maintaining self-esteem. We can help by providing supportive envi- ronments that lead to successful compensatory behav- iors. Despite years of research, we do not understand how or even whether our ability to perceive these sensations changes with age. Part of the problem has to do with how such sensations, including pain, are measured and how individual differences in tolerance affects people’s reports.
Balance. Bertha, the older woman we met in the vignette, as well as anyone riding a bicycle, is concerned about losing balance and falling. Bertha (and each of us) gets information about balance mainly from the vestib- ular system, housed deep in the inner ear, but the eyes provide important cues, too. The vestibular system is
Table 3.3
Helping People with Hearing Loss TYPE OF DEVICE HOW IT WORKS Analog hearing aid Although there are various styles, the basic design is always the same. A mold is placed in
the outer ear to pick up sound and send it through a tube to a microphone. The micro- phone sends the sound to an amplifier. The amplifier enhances the sound and sends it to the receiver. The receiver sends the amplified sound to the ear.
Digital hearing aid These are similar to analog hearing aids, but digital aids use directional microphones to control the flow of sound. Compression technology allows the sound to be increased or decreased as it rises and falls naturally in the room. Microchips allow hearing aids to be programmed for different hearing situations. This technology also uses multiple channels to deliver sound with varying amplification characteristics.
Cochlear implant The main difference between hearing aids and cochlear implants is that implants do not make the sound louder. Rather, the implant is a series of components. A microphone, usu- ally mounted behind the ear on the scalp, picks up sound. The sound is digitized by micro- chips and turned into coded signals, which are broadcast via FM radio signals to electrodes that have been inserted into the inner ear during surgery. The electrodes stimulate the auditory nerve fibers directly.
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74 CHAPTER 3
designed to respond to the forces of gravity as they act on the head and then to provide this information to the parts of the brain that initiate the appropriate movements so that we can maintain balance. The eyes send signals to the back of the brain (the occipital cortex) and provide visual cues about maintaining balance. Importantly, changes in the white matter in the frontal cortex and in the occipital cortex that occur with age have been shown to be related to difficulty in maintaining proper balance (Van Impe, Coxon, Goble, Doumas, & Swinnen, 2012). The impor- tance of white matter in aging was discussed in Chapter 2 .
Dizziness (the vague feeling of being unsteady, floating, and light-headed) and vertigo (the sensation that one or one’s surroundings are spinning) are com- mon experiences for older adults. Although age-related structural changes in the vestibular system account for some of the problems, they do not entirely account for increases in dizziness and vertigo. Also, it takes older adults longer to integrate all the other sensory infor- mation coming to the brain to control posture (Aldwin & Gilmer, 2004). And dizziness can be a side effect of certain medications and physical illnesses.
Because of these changes, the likelihood of falling increases with age, especially after age 70 (Vereeck et al., 2008). Falls may be life-threatening events for older adults, especially for those with osteoporosis, because of the increased risk of broken bones. Environmental hazards such as loose rugs and slippery floors are more likely to be a factor for healthy, community-dwelling older adults, whereas disease is more likely to play a role in institutionalized people. Increases in body sway, the natural movement of the body to maintain bal- ance, occur with increasing age. Connections between the degree of body sway and likelihood of falling have been shown, with people who fall often having more body sway (El Haber et al., 2008).
Because fear of falling has a real basis, it is impor- tant that concerns not be taken lightly (Granacher, Muehlbauer, & Gruber, 2012). Careful assessment of balance is important in understanding the nature and precise source of older adults’ problems. People can also be trained to prevent falls through tai chi (Li et al., 2008), described in detail in the How Do We Know? feature.
HOW DO WE KNOW?: PREVENTING FALLS THROUGH TAI CHI Who were the investigators, and what were the aims of the studies? Helping older adults improve their balance is an important way to help lower the risk of falling. Tai chi, an ancient Chinese martial art, enhances body awareness. Previous research had shown that tai chi is an effective approach to improving balance, but whether it could be used with typical community-dwelling older adults was unknown. Li et al. (2008) examined whether using tai chi to improve balance could be implemented in a community-based senior center.
How did the investigators measure the topic of interest? Each Tai Chi—Moving for Better Movement class began with warm-up exercises, followed by teach- ing and practicing the 8 -form variation of tai chi for 45 minutes, and ended with a 5 -minute cooldown period. Program effectiveness was measured as the change in physical performance and quality of life as indexed by the functional reach test, the up-and-go test, time to rise from a chair, the 50 -foot speed walk, and a 12 -item physical and mental health scale. Frequency of falls was monitored monthly using a falls calendar in which par- ticipants marked when falls occurred. Long-term main- tenance of the program was measured as the degree to
which participants continued during the 12 weeks after the formal program ended.
Who were the participants in the study? Partici- pants were 140 community-dwelling adults in Oregon who were over age 60 , in good health, physically mobile, and did not show any mental deficits. The study was conducted in senior centers.
What was the design of the studies? The research- ers used a pretest-posttest design to measure change. Participants took the one-hour tai chi classes twice per week for 12 weeks.
Were there ethical concerns with the study? Par- ticipants in the study were provided with informed con- sent and were closely monitored throughout the study, so there were no ethical concerns.
What were the results? Results showed that par- ticipants improved on all measures during the course of the program. No loss of improvement was observed in the 12 weeks following the end of the formal program.
What did the investigators conclude? Li and col- leagues concluded that tai chi represents an effective intervention to improve older adults’ movement to lower the risk of falling. It was easily adapted in senior centers, making it a low-cost, high-payoff intervention. Because tai chi is a low-impact martial art, it is easily adapted for use by older adults.
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PHYSICAL CHANGES 75
Taste and Smell
Taste. There is an expression “too old to cut the mus- tard,” which dates back to when people made mustard at home by grinding mustard seed and adding just the right amount of vinegar (“cutting the mustard”) to balance the taste. If too much vinegar was added, the concoction tasted terrible, so the balance was critical. Many families found that older members tended to add too much vinegar.
Despite the everyday belief that taste ability changes with age, we do not have much data docu- menting what actually happens. We do know that the ability to detect different tastes declines gradually and that these declines vary a great deal from flavor to fla- vor and person to person and the amount of experi- ence one has with particular substances (Bitnes et al., 2007). Whatever age differences we observe are not caused by a decline in the sheer number of taste buds; unlike other neural cells, the number of taste cells does not change appreciably across the life span (Imoscopi, Inelmen, Sergi, Miotto, & Manzato, 2012).
Despite the lack of evidence of large declines in the ability to taste, there is little question that older adults complain more about boring food and are at risk for malnutrition as a result (Henkin, 2008). The explana- tion may be that changes in the enjoyment of food are caused by psychosocial issues (such as personal adjust- ment), changes in smell (which we consider next), or disease. For instance, we are much more likely to eat a balanced diet and to enjoy our food when we feel well enough to cook, when we do not eat alone, and when we get a whiff of the enticing aromas from the kitchen.
Smell. “Stop and smell the roses.” “Ooh! What’s that perfume you’re wearing?” “Yuck! What’s that smell?” There is a great deal of truth in the saying “The nose knows.” Smell is a major part of our everyday lives. How something smells can alert us that dinner is cook- ing, warn of a gas leak or a fire, let us know that we are clean, or be sexually arousing. Many of our social interactions involve smell (or the lack of it). We spend billions of dollars making our bodies smell appealing to others. It is easy to see that any age-related change in sense of smell would have far-reaching consequences.
Researchers agree that the ability to detect odors remains fairly intact until the 60 s , when it begins to
decline, but there are wide variations across people and types of odors (Nordin, 2012). These variations could have important practical implications. A large survey conducted by the National Geographic Society indicated that older adults were not as able to identify particular odors as younger people. One of the odors tested was the substance added to natural gas that enables people to detect leaks—not being able to iden- tify it is a potentially fatal problem.
Abnormal changes in the ability to smell are turn- ing out to be important in the differential diagnosis of probable Alzheimer’s disease, resulting in the develop- ment of several quick tests such as the Pocket Smell Test (Steffens & Potter, 2008). According to several studies, people with Alzheimer’s disease can identify only 60 % of the odors identified by age-matched control par- ticipants; in more advanced stages of the disease, this further declined to only 40 % compared with controls. These changes give clinicians another indicator for diagnosing suspected cases of Alzheimer’s disease.
The major psychological consequences of changes in smell concern eating, safety, and pleasurable expe- riences. Odors play an important role in enjoying food and protecting us from harm. Socially, decreases
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76 CHAPTER 3
in our ability to detect unpleasant odors may lead to embarrassing situations in which we are unaware that we have body odors or need to brush our teeth. Social interactions could suffer as a result of these problems. Smells also play a key role in remembering life experi- ences from the past. Who can forget the smell of cook- ies baking in Grandma’s oven? Loss of odor cues may mean that our sense of the past suffers as well.
about Steve’s symptoms. We’ll also discover why figuring out the pattern of age-related changes in the respiratory system is very difficult (here’s a tip—it has to do with biological-psychological-environmental interactions).
Overall, the age-related changes in the cardiovas- cular and respiratory systems are excellent examples of how the forces of development interact. On the bio- logical front, we know that some cardiovascular and respiratory diseases have important genetic links. Psy- chologically, certain personality traits have been linked with increased risk of disease. Socioculturally, some cardiovascular and respiratory diseases are clearly tied to lifestyle. The impact of both cardiovascular and respiratory diseases also differs as a function of age. Let’s explore in more detail how these various forces come together.
Cardiovascular System Tune into your pulse. The beating of your heart is the work of an amazing organ. In an average lifetime, the heart beats more than 3 billion times, pumping the equivalent of more than 900 million gallons of blood. Two important age-related structural changes in the heart are the accumulation of fat deposits and the stiffening of the heart muscle caused by tissue changes. By the late 40 s and early 50 s , the fat deposits in the lining around the heart may form a continuous sheet. Meanwhile, healthy muscle tissue is being replaced by connective tissue, which causes a thickening and stiff- ening of the heart muscle and valves. These changes reduce the amount of muscle tissue available to con- tract the heart. The net effect is that the remaining muscle must work harder. To top it off, the amount of blood that the heart can pump declines from roughly 5 liters per minute at age 20 to about 3.5 liters per minute at age 70 (National Institute on Aging, 2012a).
The most important change in the circulatory sys- tem involves the stiffening (hardening) of the walls of the arteries. These changes are caused by calcification of the arterial walls and by replacement of elastic fibers with less elastic ones.
The combination of changes in the heart and the circulatory system results in a significant decrease in a person’s ability to cope with physical exertion, espe- cially aerobic exercise. By age 65 , the average adult has experienced a 60 to 70 % decline in the aerobic capacity since young adulthood. However, if you stay in good
Adult Development in Action If you were a consultant asked to design the optimal home environment for older adults, what specific design features would you include that would provide support for normative age-related sensory changes? (Keep your answer and refer to it in Chapter 5 .)
3.4 Vital Functions LEARNING OBJECTIVES
What age-related changes occur in the cardiovascular system? What types of cardiovascular disease are common in adult development and aging? What are the psychological effects of age-related changes in the cardiovascular system?
What structural and functional changes occur with age in the respiratory system? What are the most common types of respiratory diseases in older adults? What are the psychological effects of age-related changes in the respiratory system?
Steve is an active 73 -year-old man who walks and plays golf regularly. He smoked earlier in his life, but he quit years ago. He also watches his diet to control fat intake. Steve recently experienced some chest pains and sweating but dismissed it as simply age-related. After all, he thinks, I take care of myself. However, Steve’s wife, Grace, is con- cerned he may have a more serious problem.
You cannot live without your cardiovascular (heart and blood vessels) and your respiratory (lungs and air passageways) systems; that’s why they are called vital functions. Each undergoes important normative changes with age that can affect the quality of life. In this sec- tion, we’ll find out whether Grace has reason to worry
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PHYSICAL CHANGES 77
shape throughout adulthood, the decline is much less (National Institute on Aging, 2012a). This decline is one reason why older adults who are not in good shape are more likely to have heart attacks while performing moderately exerting tasks such as shoveling snow. The changes that occur with aging in the heart related to exercise are shown in Figure 3.5 .
Cardiovascular Diseases. In the United States, more than 30 % of the people currently have some form of cardiovascular disease; by 2030 this will rise to over 40 % (Roger, Go, Lloyd-Jones, Benjamin, Berry, Borden et al., 2012). It is the leading cause of death in all ethnic groups in the United States and in many other coun- tries. The incidence of cardiovascular disease increases dramatically with age, with the rates for men higher until age 75 for coronary heart disease and for women higher for stroke. Incidence rates over age 75 tend to converge for men and women. How cardiovascular disease dominates causes of death in the United States in people under and over age 85 is shown in Figure 3.6 .
In terms of ethnic differences in various types of cardiovascular disease, African Americans, American Indians, and Native Hawaiians have the highest rates of hypertension (high blood pressure; we will consider this condition a bit later), and Asian Americans have the lowest rate of heart disease (Roger et al., 2012). In part these differences are due to genetics, and in part they are due to life style and inadequate access to health care.
Rates of cardiovascular disease have been declin- ing in the United States among men since the 1980s (Roger et al., 2012). These declines may be deceiv- ing, though, because key risk factors are actually increasing; for example, roughly two-thirds of adults are classified as overweight, and rates of diabetes are going up.
Several types of cardiovascular disease are note- worthy. Congestive heart failure occurs when cardiac output and the ability of the heart to contract severely decline, making the heart enlarge, pressure in the veins increase, and the body swell. Congestive heart failure is
At the start of heart beat, at rest.
At the end of heart beat, at rest.
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Old Heart
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During Vigorous Exercise
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Figure 3.5 The Heart: Young and Old. Source: National Institute on Aging (2008). Aging Hearts and Arteries: A Scientific Quest . Retreived September 3, 2008, from http://www.nia.nih.gov/HealthInformation/Publications/AgingHeartsandArteries/default.htm . Design by Levine and Associates, Washington, DC.
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78 CHAPTER 3
the most common cause of hospitalization for people over age 65 . Angina pectoris occurs when the oxygen supply to the heart muscle becomes insufficient, result- ing in chest pain. Angina may feel like chest pressure, a burning pain, or a squeezing that radiates from the chest to the back, neck, and arms (Mayo Clinic, 2011b). In most cases the pain is induced by physical exertion and is relieved within 5 to 10 minutes by rest. The most common treatment of angina is nitroglycerine, although in some cases coronary arteries may need to be cleared through surgical procedures or replaced through coronary bypass surgery.
Heart attack, called myocardial infarction (MI), occurs when blood supply to the heart is severely reduced or cut off. Mortality after a heart attack is much higher for older adults (Centers for Disease Control and Pre- vention, 2012a). The initial symptoms of an MI are identical to those of angina but typically are more severe and prolonged; there may also be nausea, vom- iting, severe weakness, and sweating, which Steve experienced in the vignette. Thus, Grace is right to be concerned about Steve’s symptoms. However, chest pain may be absent in women and older adults, result- ing in so-called silent heart attacks (National Institutes
of Health, 2011). Treating heart attack victims of all ages includes careful evaluation and a prescribed reha- bilitation program consisting of lifestyle changes in diet and exercise.
Atherosclerosis. Is an age-related disease caused by the buildup of fat deposits on and the calcification of the arterial walls (National Heart, Lung and Blood Institute, 2011). A diagram depicting atherosclerosis is shown in Figure 3.7 . Much like sandbars in a river or mineral deposits in pipes, the fat deposits interfere with blood flow through the arteries. These depos- its begin very early in life and continue throughout the life span. Some amount of fat deposit inevitably occurs and is considered a normal part of aging. However, excess deposits may develop from poor nutrition, smoking, and other aspects of an unhealthy lifestyle.
When severe atherosclerosis occurs in blood vessels that supply the brain, neurons may not receive proper nourishment, causing them to mal- function or die, a condition called cerebrovascular disease. When the blood flow to a portion of the brain is completely cut off, a cerebrovascular accident
Figure 3.6 Cardiovascular disease (CVD) and other major causes of death: Total, < 85 years of age, and ≥ 85 years of age. Source: National Center for Health Statistics and National Heart, Lung, and Blood Institute.
0
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Alzheimer’s Disease CLRD Cancer
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PHYSICAL CHANGES 79
(CVA), or stroke, results . Estimates are that every 40 seconds someone in the United States has a CVA, making stroke one of the most common forms of cardiovascular disease (Centers for Disease Control and Prevention, 2012b). Causes of CVAs include clots that block blood flow in an artery or the actual breaking of a blood vessel, which creates a cerebral hemorrhage. The severity of a CVA and likelihood of recovery depend on the specific area of the brain involved, the extent of disruption in blood flow, and the duration of the disruption. Consequently, a CVA may affect such a small area that it goes almost
unnoticed, or it may be so severe as to cause death. Two common problems following a CVA are aphasia (problems with speech) and hemiplegia (paralysis on one side of the body).
The risk of a CVA increases with age; in fact, CVAs are among the leading causes of death and chronic disorders among older adults in the United States (Centers for Disease Control and Prevention, 2012b). In addition to age, other risk factors include being male, being African American, and having high blood pressure, heart disease, or diabetes. The higher risk among African Americans appears to be caused
Normal blood flow
Abnormal blood flow Plaque
PlaqueNarrowed artery
Artery cross-section
Artery wall
Normal artery(A)
(B) Narrowing of artery
Figure 3.7 Normal artery and atherosclerosis. (A) shows a normal artery with normal blood flow. (B) shows an artery with plaque buildup. Source: National Heart, Lung and Blood Institute (2011). Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/atherosclerosis/.
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80 CHAPTER 3
by a greater prevalence of hypertension in this popu- lation compounded by poorer quality and access to health care in general (Centers for Disease Control and Prevention, 2012c).
Treatment of CVA has advanced significantly. The most important advance is use of the clot-dissolving drug tissue plasminogen activator (tPA) to treat CVAs (Saver, Fonarow, Smith, Reeves, Grau-Sepulveda, Pan et al., 2013). Currently, tPA is the only approved treat- ment for CVAs caused by blood clots, which constitute 80 % of all CVAs. Not every patient should receive tPA treatment, and tPA is effective only if given promptly, which is vitally important. So if you or a person you know thinks they are experiencing a CVA, get medi- cal attention immediately, because tPA therapy must be started within 3 hours after the onset of a stroke to be most effective. Recovery from CVA depends on the severity of the stroke, area and extent of the brain affected, and patient age.
Besides blood clots, high blood pressure plays a major role in CVAs. (Do you know what yours is?) Blood pressure consists of measuring two types of pres- sure: the pressure during the heart’s contraction phase when it is pumping blood through the body, called the systolic pressure, and the pressure during the heart’s relaxation phase between beats, called the diastolic pressure. The systolic pressure is always given first. On average, a blood pressure of 120 over 80 mm Hg (mil- limeters of mercury, the scale on which the pressure is measured) is considered optimal for adults.
As we grow older, blood pressure tends to increase normally, mostly because of structural changes in the cardiovascular system. When blood pressure increases become severe, defined as 140 mm Hg or more systolic pressure (the top number in a blood pressure reading) or 90 mm Hg or more diastolic pressure (the lower number in the reading), the disease hypertension results ( WebMD. com , 2012a). Nearly 30 % of the population age 18 and older has some degree of hypertension (Yoon, Burt, Louis, & Carroll, 2012). This rate is roughly the same for Euro- pean Americans and Mexican Americans, but jumps to about 40 % among African Americans. This difference may be caused by a genetic mutation affecting enzymes that help control blood pressure and by environmental factors related to stress, poor access to health care, and poverty.
Hypertension is a disease you ignore at the risk of greatly increasing your chances of dying. Older adults
with hypertension have three times the risk of dying from cardiovascular disease, and it has important neg- ative effects on cognitive abilities and a host of other organs including kidney function (Yoon et al., 2012). Because hypertension is a disease with no clear symp- toms, most people with undiagnosed hypertension are not aware they have a problem. Regular blood pressure monitoring is the only sure way to find out whether you have hypertension. It could save your life.
What causes this silent killer? Several suspected causes are obesity, stress, lack of exercise, and dietary sodium (salt) (WebMD, 2011a). All of these causes are related to life style and are under one’s control. Genetic links have been identified as well.
Too much sodium (salt) is a factor that many peo- ple overlook. Eating sodium in one’s diet is essential for life because the body needs a certain amount each day to regulate blood pressure and blood volume properly (McGee, 2007). However, too much sodium can have several very bad effects on health: In addition to hyper- tension, it can cause congestive heart failure and kid- ney disease (McGee, 2007). Sodium occurs naturally in many foods, such as raw celery, many cheeses, and scallops. It is also present in nearly all processed foods, often in high concentrations; for example, one serving of typical saltine crackers contains 1,100 milligrams , pretzels have 1,650 , and a hot dog about 1,100 . When you consider that the American Heart Association (2011) recommends that adults should not consume more than 1,500 milligrams per day (about a teaspoon), it is clear that getting too much sodium is easy to do.
Another chronic cardiovascular condition that is discussed less often is hypotension, or low blood pres- sure. Symptoms of hypotension include dizziness or light-headedness that is caused most commonly when you stand up quickly after lying down or sitting, or sometimes after eating (WebMD, 2011b). Hypoten- sion often is related to anemia and is more common in older adults. Although hypotension per se is not a dan- gerous condition, the resulting dizziness can increase the likelihood of fainting and falls, which may result in more serious injury.
Respiratory System You probably don’t pay much attention to your breath- ing unless you’re gasping for breath after exercise— or you’re an older adult. Older adults tend to notice
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PHYSICAL CHANGES 81
their breathing a great deal more. Why? With increas- ing age, the rib cage and the air passageways become stiffer, making it harder to breathe. The lungs change in appearance over time, going gradually from their youthful pinkish color to a dreary gray, caused mainly by breathing in carbon particles (from air pollution). The maximum amount of air we can take into the lungs in a single breath begins to decline in the 20 s , decreasing by 40 % by age 85 . And the rate at which we can exchange oxygen for carbon dioxide drops sig- nificantly as the membranes of the air sacs in the lungs deteriorate (Pride, 2005).
One of the difficulties in understanding age- related changes in the respiratory system is that it is hard to know how much of the change is caused spe- cifically by normative developmental factors and how much is caused by environmental factors. For exam- ple, it is difficult to determine how much age-related change in respiratory function is due to air pollution.
Respiratory Diseases. The most common and inca- pacitating respiratory disorder in older adults is chronic obstructive pulmonary disease (COPD), a family of diseases that includes chronic bronchitis and emphy- sema . By 2012, COPD was the third-leading-cause of death in the United States, with rates higher in women than in men. Smoking is the most important cause of COPD, but secondhand smoke, air pollution, and industrial dusts and chemicals can also cause it (American Lung Association, 2012).
Emphysema is the most serious type of COPD and is characterized by the destruction of the membranes around the air sacs in the lungs (WebMD, 2012b). This irreversible destruction creates holes in the lung, dras- tically reducing the ability to exchange oxygen and carbon dioxide. To make matters worse, the bron- chial tubes collapse prematurely when the person exhales, thereby preventing the lungs from emptying completely. Emphysema is a very debilitating disease. In its later stages, even the smallest physical exertion causes a struggle for air. People with emphysema may have such poorly oxygenated blood that they become confused and disoriented. About 95 % of the cases of emphysema are self-induced by smoking; the remain- ing cases are caused by a genetic deficiency of a protein known as an a 1 -antitrypsin (WebMD, 2012b). This protein, a natural “lung protector,” is made by the liver;
when it is missing, emphysema is inevitable. Although some drugs are available to help ease breathing, lung transplantation remains a treatment of last resort for people with emphysema, especially in the genetic form of the disease.
Chronic bronchitis can occur at any age, but it is more common in people over age 45 , especially among people who are exposed to high concentrations of dust, irritating fumes, and air pollution. Treatment usually consists of medication (called bronchodilators) to open bronchial passages and a change of work environment. Similarly, asthma is another very common respiratory disease that is increasing in prevalence. Treatment for asthma also involves the use of bronchodilators.
Overall, treatment for COPD needs to begin as soon as a problem is diagnosed. That may involve stopping smoking (the best treatment available for smokers). In other cases, supplemental oxygen or using glucocorticosteroid medications may provide some relief. The thing to remember, though, is that the damage caused by COPD is irreversible.
3.5 The Reproductive System LEARNING OBJECTIVES
What reproductive changes occur in women? What reproductive changes occur in men? What are the psychological effects of reproductive
changes?
Helen woke up in the middle of the night drenched in sweat. She’d been feeling fine when she went to bed after her 48 th birthday party, so she wasn’t sure what was the matter. She thought she was too young to experi- ence menopause. Helen wonders what other things she’ll experience.
As you probably surmised, Helen has begun going through “the change,” a time of life that many women
Adult Development in Action If you ran a training program for personal exercise trainers, what age-related changes in vital functions would you emphasize?
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82 CHAPTER 3
look forward to and just as many see as the begin- ning of old age. For women like Helen, “the change” is the defining physiological event in middle age. Men do not endure such sweeping biological changes but experience several gradual changes instead. Beyond the physiological effects, these changes have important psychological implications because many people think midlife is a key time for redefining ourselves. Let’s see how the experience differs for women and men.
Female Reproductive System As Helen is beginning to experience, the major repro- ductive change in women during adulthood is the loss of the natural ability to bear children. As women enter midlife, they experience a major biological process, called the climacteric , during which they pass from their reproductive to nonreproductive years. Menopause is the point at which menstruation stops .
The major reproductive change in women during adulthood is the loss of the ability to bear children. This change begins in the 40 s as menstrual cycles become irregular, and by age 50 to 55 it is usually complete (Vorvick, 2010). This time of transition from regular menstruation to menopause is called perimenopause , and how long it lasts varies considerably . The gradual loss and eventual end of monthly periods is accompa- nied by decreases in estrogen and progesterone levels, changes in the reproductive organs, and changes in sexual functioning
A variety of physical and psychological symp- toms may accompany perimenopause and menopause with decreases in hormonal levels ( WomensHealth. gov , 2010a): hot flashes, night sweats, headaches, sleep problems, mood changes, more urinary infections, pain during sex, difficulty concentrating, vaginal dry- ness, less interest in sex, and an increase in body fat around the waist. Many women report no symptoms at all, but most women experience at least some, and there are large differences across social, ethnic, and cultural groups in how they are expressed (Nosek, Kennedy, & Gudmundsdottir, 2012; Utian, 2005). For example, women in the Mayan culture of Mexico and Central America welcome menopause and its changes as a natural phenomenon and do not attach any stigma to aging (Mahady et al., 2008). In the United States, Latinas and African Americans, especially working- class women, tend to view menopause more positively,
whereas European American women describe it more negatively (Dillaway et al., 2008). Women in South American countries report a variety of symptoms that impair quality of life, many of which persist five years beyond menopause (Blümel, Chedraui, Baron, Bel- zares, Bencosme, Calle, et al., 2012).
The decline in estrogen that women experience after menopause is related to increased risk of osteo- porosis, cardiovascular disease, stress urinary inconti- nence (involuntary loss of urine during physical stress, as when exercising, sneezing, or laughing), weight gain, and memory loss (Dumas et al., 2010; Mayo Clinic, 2012b). In the case of cardiovascular disease, at age 50 (prior to menopause) women have 3 times less risk of heart attacks than men on average. Ten years after menopause, when women are about 60 , their risk equals that of men.
In response to these increased risks and to the estrogen-related symptoms that women experience, one approach is the use of menopausal hormone therapy (MHT) : women take low doses of estrogen, which is often combined with progestin (synthetic form of pro- gesterone) . Hormone therapy is controversial and has been the focus of many research studies with conflict- ing results (Bach, 2010; Mayo Clinic, 2012b). There appear to be both benefits and risks with MHT, as dis- cussed in the Current Controversies Feature.
CURRENT CONTROVERSIES: MENOPAUSAL HORMONE THERAPY For many years, women have had the choice of tak- ing medications to replace the female hormones that are no longer produced naturally by the body after menopause. Hormone therapy may involve taking estrogen alone or in combination with progesterone (or progestin in its synthetic form). Research on the effects of menopause hormone therapy have helped clarify the appropriate use of such medications.
Until about 2003, it was thought that meno- pausal hormone therapy (MHT) was beneficial for most women, and results from several studies were positive. But results from the Women’s Health Ini- tiative research in the United States and from the Million Women Study in the United Kingdom indi- cated that, for some types of MHT, there were several potentially serious side effects. As a result, physicians are now far more cautious in recommending MHT.
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PHYSICAL CHANGES 83
Women’s genital organs undergo progressive change after menopause. The vaginal walls shrink and become thinner, the size of the vagina decreases, vaginal lubrica- tion is reduced and delayed, and the external genitalia shrink somewhat. These changes have important effects on sexual activity, such as an increased possibility of painful intercourse and a longer time and more stimula- tion needed to reach orgasm. Failure to achieve orgasm is more common in midlife and beyond than in a wom- an’s younger years. However, maintaining an active sex life throughout adulthood lowers the degree to which problems are encountered. Despite these changes, there is no physiological reason not to continue having an active and enjoyable sex life from middle age through late life. The vaginal dryness that occurs, for example, can be countered by using personal lubricants, such as K-Y or Astroglide .
Whether women continue to have an active sex life has a lot more to do with the availability of a suitable partner than a woman’s desire for sexual relations. This is especially true for older women. The AARP Mod- ern Maturity sexuality study (AARP, 1999), the Sex in America study (Jacoby, 2005), and the Sex, Romance, and Relationships (Fisher, 2010) studies all found that older married women were far more likely to have an active sex life than unmarried women. The primary reason for the decline in women’s sexual activity with age is the lack of a willing or appropriate partner, not a lack of physical ability or desire (AARP, 1999; Fisher, 2010; Jacoby, 2005).
Male Reproductive System Unlike women, men do not have a physiological (and cultural) event to mark reproductive changes, although there is a gradual decline in testosterone levels (Bribi- escas, 2010) that can occur to a greater extent in men who are obese or have diabetes (Nigro & Christ-Crain, 2012). Men do not experience a complete loss of the ability to father children, as this varies widely from
The Women’s Health Initiative (WHI), begun in the United States in 1991, was a very large study (National Heart, Lung, and Blood Institute, 2003). The estrogen plus progestin trial used 0.625 mil- ligram of estrogen taken daily plus 2.5 milligrams of medroxyprogesterone acetate (Prempro) taken daily. This combination was chosen because it is the mostly commonly prescribed form of the combined hormone therapy in the United States and, in sev- eral observational studies, had appeared to benefit women’s health. The women in the WHI estrogen plus progestin study were aged 50 to 79 when they enrolled in the study between 1993 and 1998. The health of study participants was carefully moni- tored by an independent panel called the Data and Safety Monitoring Board (DSMB). The study was stopped in July 2002 because investigators discov- ered a significant increased risk for breast cancer and that overall the risks outnumbered the ben- efits. However, in addition to the increased risk of breast cancer, heart attack, stroke, and blood clots, MHT resulted in fewer hip fractures and lower rates of colorectal cancer.
The Million Women Study began in 1996 and includes 1 in 4 women over age 50 in the United Kingdom, the largest study of its kind ever con- ducted. Like the Women’s Health Initiative, the study examined how MHT (both estrogen/progestin com- binations and estrogen alone) affects breast cancer, cardiovascular disease, and other aspects of women’s health. Results from this study confirmed the Wom- en’s Health Initiative outcome of increased risk for breast cancer associated with MHT.
The combined results from the WHI and the Million Women Study led physicians to recommend that women over age 60 should not begin MHT to relieve menopausal symptoms or protect their health. In fact, women over age 60 who begin MHT are at increased risk for certain cancers.
In sum, women face difficult choices when deciding whether to use MHT as a means of com- batting certain menopausal symptoms and protect- ing themselves against other diseases. For example, MHT can help reduce hot flashes and night sweats, help reduce vaginal dryness and discomfort during sexual intercourse, slow bone loss, and perhaps ease mood swings. On the other hand, MHT can increase a woman’s risk of blood clots, heart attack, stroke, breast cancer, and gallbladder disease.
The best course of action is to consult closely with one’s physician to weigh the benefits and risks. It’s also a good idea to keep in mind several key points ( WomensHealth.gov , 2010b):
Once a woman reaches menopause, MHT is recommended only as a short-term treatment.
Doctors very rarely recommend MHT to prevent certain chronic diseases like osteoporosis.
Women who have gone through menopause should not take MHT to prevent heart disease.
MHT should not be used to prevent memory loss, dementia, or Alzheimer’s disease.
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84 CHAPTER 3
individual to individual, but men do experience a normative decline in the quantity of sperm (Dugdale, 2012). However, even at age 80 a man is still half as fertile as he was at age 25 and is quite capable of father- ing a child.
With increasing age the prostate gland enlarges, becomes stiffer, and may obstruct the urinary tract. Prostate cancer becomes a real threat during middle age; annual screenings are often recommended for men over age 50 (American Cancer Society, 2012a).
Men experience some physiological changes in sexual performance. By old age, men report less per- ceived demand to ejaculate, a need for longer time and more stimulation to achieve erection and orgasm, and a much longer resolution phase during which erec- tion is impossible (Saxon & Etten, 1994). Older men also report more frequent failures to achieve orgasm and loss of erection during intercourse (AARP, 1999; Fisher, 2010; Jacoby, 2005). However, the advent of Viagra, Cialis, and other medications to treat erectile dysfunction has provided older men with easy-to-use medical treatments and the possibility of an active sex life well into later life.
As with women, as long as men enjoy sex and have a willing partner, sexual activity is a lifelong option. Also as with women, the most important ingredient of sexual intimacy for men is a strong relationship with a partner (AARP, 1999; Fisher, 2010; Jacoby, 2005). For example, married men in early middle age tend to have intercourse four to eight times per month. The loss of an available partner is a significant reason frequency of intercourse drops on average by two and three times per month in men over age 50 and 60 , respectively (Araujo, Mohr, & McKinlay, 2004).
Psychological Implications Older adults say that engaging in sexual behavior is an important aspect of human relationships throughout adulthood (AARP, 1999; Fisher, 2010; Jacoby, 2005). Healthy adults at any age are capable of having and enjoying sexual relationships. Moreover, the desire to do so normally does not diminish. Unfortunately, one of the myths in our society is that older adults cannot and should not be sexual. Many young adults find it dif- ficult to think about their grandparents having great sex.
Such stereotyping has important consequences. What do you think to yourself when we see an older
couple being publicly affectionate? Can you envision your grandparents enjoying an active sex life? Many people feel that such behavior is cute. But observers tend not to refer to their own or their peers’ relation- ships in this way. Many nursing homes and other insti- tutions actively dissuade their residents from having sexual relationships and may even refuse to allow mar- ried couples to share the same room. Adult children may believe their widowed parent does not have the right to establish a new sexual relationship. The mes- sage we are sending is that sexual activity is fine for the young but not for the old. The major reason why older women do not engage in sexual relations is the lack of a socially sanctioned partner. It is not that they have lost interest; rather, they believe they are simply not per- mitted to express their sexuality any longer.
3.6 The Autonomic Nervous System LEARNING OBJECTIVES
What major changes occur in the autonomic nervous system?
What are the psychological effects of changes in the autonomic nervous system?
Jorge is an active 83 -year-old former factory worker who lives with his wife, Olivia, in a crowded apartment in Los Angeles. Over the past few years, Jorge has had increasing difficulty handling the heat of southern California sum- mers. Olivia has noticed that Jorge takes more naps during the day and sleeps poorly at night. Jorge and Olivia wonder whether there is something wrong with him.
As we saw in Chapter 2 , our brains are the most complex structures yet discovered in the universe. Everything that makes us individuals is housed in the brain, and we are only now beginning to unlock its mys- teries through the techniques described in Chapter 2 .
In this section, we build in the changes we encoun- tered in Chapter 2 and turn our attention to the
Adult Development in Action As a gerontologist, what do you think should be done to create a more realistic view of reproductive changes and interest in sex across the adult lifespan?
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PHYSICAL CHANGES 85
autonomic nervous system (nerves in the body outside the brain and spinal column). Jorge’s experiences are related to changes in the autonomic nervous system; we’ll discover whether Jorge’s problems are normative.
Autonomic Nervous System Do you feel hot or cold right now? Do your palms sweat when you get nervous? What happens when you get frightened? These and other regulation functions in your body are controlled by the autonomic nervous system. Fortunately, few changes occur in the auto- nomic nervous system as we age, but two changes do tend to get people’s attention: body temperature con- trol and sleep. Jorge, whom we met in the vignette, is experiencing both of these changes.
Regulating Body Temperature. Every year, news- casts around the world report that during very cold or very hot spells more older adults die than people in other age groups. Why does this happen? We con- sidered evidence earlier in this chapter that cold and warm temperature thresholds may change little. If older people can feel cold and warm stimuli placed against them about as well as people of other age groups, what accounts for these deaths?
It turns out that older adults have difficulty tell- ing that their core body temperature is low (Blatteis, 2012). In other words, older people are much less likely to notice that they are cold. Regulating body tempera- ture involves nearly all body systems, most of which undergo declines with age. Because some of them respond to training (e.g., fitness training can help with declines in the musculoskeletal system), some causes of the declines can be addressed. However, changes in the skin and metabolic systems are inevitable. To make matters worse, older adults also have slower vasocon- strictor response, which is the ability to raise core body temperature (i.e., warm up) when the body’s peripheral temperature drops (Blatteis, 2012; DeGroot & Kenney, 2007; Van Someren, 2007).
Similarly, older adults have trouble responding to high heat, because they do not sweat as much (Blatteis, 2012). Sweating decreases with age from the lower limbs up to the forehead, and is due to lower sweat production.
Taken together, the difficulties older adults have in regulating body temperature in extreme cold and heat are the primary reason why older adults are much more susceptible to hypothermia (body temperature below
95 °F over a long period) and hyperthermia (body tem- perature above 98.6 °F that cannot be relieved by sweat- ing) (Blatteis, 2012). This is why social service agencies are especially mindful of older adults during major weather events.
Sleep and Aging. How did you sleep last night? If you are older, chances are that you had some trouble. In fact, sleep complaints and problems are common in older adults (Wolkove et al., 2007a). These complaints most often concern difficulty in falling asleep, fre- quent or prolonged awakenings during the night, early morning awakenings, and a feeling of not sleeping very well. Effects of poor sleep are experienced the next day; moodiness, poorer performance on tasks involving sustained concentration, fatigue, and lack of motiva- tion are some of the telltale signs.
Nearly every aspect of sleep undergoes age-related changes (Wolkove et al., 2007a). It takes older adults
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86 CHAPTER 3
involved in numerous age-related changes. Whether interventions that are aimed at helping insomniacs find their optimal body temperature for sleeping will work remains to be seen.
As we now know, Jorge’s difficulty with heat and sleep reflect normative changes that occur with age. Olivia should be informed of these changes and encouraged to make sure Jorge drinks plenty of water and adopts good sleep habits.
Psychological Implications Being able to maintain proper body temperature can literally be a matter of life and death. So the increased difficulty in doing that poses a real threat to older adults. Being in an environment that provides exter- nal means of temperature regulation (i.e., heating and air conditioning), and that has back-up systems in the event of emergency (e.g., generators in the event of power failures) are much more important for older adults.
Because thermoregulation involves so many of the body’s systems, and because many of the age-related changes that occur are inevitable, it is important to focus on those systems that respond to intervention. By doing whatever is possible to keep those systems functioning as well as possible, people can lessen the overall problem of regulating body temperature.
A good night’s sleep is also important for main- taining good overall health. Ensuring that the sleep environment is maximally conducive to sleeping and by providing whatever environmental supports pos- sible, we can increase the odds of improving sleep.
longer to fall asleep, they are awake more at night, they are more easily awakened, and they experience major shifts in their sleep–wake cycles, called circa- dian rhythms. Across adulthood, circadian rhythms move from a two-phase pattern of sleep (awake dur- ing the day and asleep at night for most people) to a multiphase rhythm reminiscent of that of infants (daytime napping and shorter sleep cycles at night). These changes are related to the changes in regulating core body temperature discussed earlier. Other major causes of sleep disturbance include sleep apnea (stop- ping breathing for 5 to 10 seconds), periodic leg jerks, heartburn, frequent need to urinate, poor physical health, and depression.
Older adults try lots of things to help themselves, such as taking daytime naps, without success (Wolk- ove et al., 2007b). As a result, many older adults are prescribed sleeping pills or hypnotic sedatives. But these medications must be used with great caution with older adults, and often do not help alleviate the problem in any case. Among the most effective treat- ments of sleep problems are increasing physical exer- cise, reducing caffeine intake, avoiding daytime naps, and making sure that the sleeping environment is as quiet and dark as possible (Passarella & Duong, 2008; Wolkove et al., 2007b).
Some research has linked the need for sleep to the amount of brain activity devoted to learning that occurred prior to sleep (Cirelli, 2012). So one hypoth- esis is that sleep needs decrease with age in relation to decreased new learning that occurs with age. How- ever, research specifically examining this hypothesis remains to be done.
Research evidence also points to difficulties in reg- ulating the optimal body temperature for good sleep may also be part of the issue for older adults (Romeijn, Raymann, Most, Te Lindert, Van Der Meijden, Fronczek, et al., 2012). Interestingly, this problem may in turn be related to changes in the frontal cortex, a key part of the brain that is involved in evaluating com- fort. As we saw in Chapter 2 , this part of the brain is
BEGIN ADULT DEVELOPMENT IN ACTION: ADULT DEVELOPMENT IN ACTIONS What would be the best questions to ask an older adult client if you, as a social worker, were establish- ing whether the client had any problems with toler- ating heat/cold or sleeping?
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PHYSICAL CHANGES 87
SOCIAL POLICY IMPLICATIONS No one wants to fall and get hurt. That’s true in any age group, but especially so with older adults, par- ticularly older adults who live alone. The fear of fall- ing is real, and even has been used as the basis for a famous television ad for an emergency alert system: An older woman is shown falling and saying, “I’ve fallen, and I can’t get up.” (Check out the original ad and the remixes on YouTube.)
Because of normative age-related changes in vision, hearing, balance, musculoskeletal changes, and other aspects of functioning, the risk of falling increases with age. As you can see in Figure 3.8 , that increase is quite dramatic over age 75 .
Falls can result in serious injuries or even death to older adults. People with osteoporosis are especially vulnerable to breaking their hip or pelvis, or may suf- fer a traumatic brain injury, any of which may necessi- tate a long rehabilitation. As a result, much attention has been paid to preventing falls. Some of these inter- ventions are simple (such as removing loose floor rugs and ensuring that there is sufficient light and reduced glare). Others involve life style changes or technology.
The Centers for Disease Control and Prevention (2012d) have translated the research findings about increased risk and consequences of falls in older adults and have created several suggestions on how to prevent them. Among their suggestions are:
Get exercise to strengthen muscles. Programs such as the Tai Chi program discussed in the How Do We Know? feature are effective.
Be careful of medication side effects. Some medications may cause dizziness or drowsiness, which can increase the risk for falling.
Correct any visual impairments to the extent possible.
Remove hazards at home. Remove clutter you can trip over (books, clothes, and other materials on the floor). Install handrails on stairways. Use non- slip mats and grab bars in showers and bath tubs.
The materials compiled by the Centers for Disease Control and Prevention include posters and brochures in Spanish and Chinese, as well as more for- mal booklets for community-based programs. These recommendations, if followed, would result in a safer environment for older adults.
Total <12 12–17 18–44
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0
20
40
60
80
100
120
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160
45–64 65–74 �75
Figure 3.8 The figure shows the rate of nonfatal, medically consulted fall injury episodes, by age group, in the United States during 2010, according to the National Health Interview Survey. In 2010, the overall rate of nonfatal fall injury episodes for which a health-care professional was contacted was 43 per 1,000 population. Rates increased with age for adults aged ≥ 18 years. Persons aged 18 – 44 years had the lowest rate of medically consulted falls ( 26 per 1,000 ), and persons aged ≥ 75 years had the highest rate ( 115 ). Source: Adams PF, Martinez ME, Vickerie JL, Kirzinger WK. Summary health statistics for the U.S. population: National Health Interview Survey, 2010. Vital Health Stat 2011;10(251). http://www.cdc.gov/ mmwr/preview/mmwrhtml/mm6104a8.htm
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88 CHAPTER 3
3.2 Appearance and Mobility
How do our skin, hair, and voice change with age? Normative changes with age in appearance or pre-
sentation include wrinkles, gray hair, and thinner and weaker voice.
What happens to our body build with age? Normative changes include decrease in height and
increase in weight in midlife, followed by weight loss in late life.
What age-related changes occur in our ability to move around?
The amount of muscle decreases with age, but strength and endurance change only slightly.
Loss of bone mass is normative; in severe cases, though, the disease osteoporosis may result, in which bones become brittle and honeycombed.
Osteoarthritis and rheumatoid arthritis are two dis- eases that impair a person’s ability to get around and function in the environment.
What are the psychological implications of age-related changes in appearance and mobility?
Cultural stereotypes have an enormous influence on the personal acceptance of age-related changes in appearance.
Loss of strength and endurance, and changes in the joints, have important psychological consequences, especially regarding self-esteem.
3.3 Sensory Systems
What age-related changes happen in vision? Several age-related changes occur in the structure
of the eye, including decreases in the amount of light passing through the eye and in the ability to adjust to changes in illumination, yellowing of the lens, and changes in the ability to adjust and focus (presbyopia). In some cases these changes result in various diseases, such as cataracts and glaucoma.
Other changes occur in the retina, including degen- eration of the macula. Diabetes also causes retinal degeneration.
The psychological consequences of visual changes include difficulties in getting around. Compensation strategies must take several factors into account; for example, the need for more illumination must be weighed against increased susceptibility to glare.
Summary 3.1 Why Do We Age? Biological Theories of Aging
How do rate-of-living theories explain aging? Rate-of-living theories are based on the idea that
people are born with a limited amount of energy that can be expended at some rate unique to the individual.
Metabolic processes such as eating fewer calo- ries or reducing stress may be related to living longer.
The body’s declining ability to adapt to stress with age may also be a partial cause of aging.
What are the major hypotheses in cellular theories of aging?
Cellular theories suggest that there may be a limit on how often cells may divide before dying (called the Hayflick limit), which may partially explain aging. The shortening of telomeres may be the major factor.
A second group of cellular theories relate to a pro- cess called cross-linking that results when certain proteins interact randomly and produce molecules that make the body stiffer. Cross-links interfere with metabolism.
A third type of cellular theory proposes that free radicals, which are highly reactive chemicals pro- duced randomly during normal cell metabolism, cause cell damage. There is some evidence that ingesting antioxidants may postpone the appear- ance of some age-related diseases.
How do programmed-cell-death theories propose that we age?
Theories about programmed cell death are based on genetic hypotheses about aging. Specifically, there appears to be a genetic program that is trig- gered by physiological processes, the innate ability to self-destruct, and the ability of dying cells to trig- ger key processes in other cells.
How do the basic developmental forces interact in biological and physiological aging?
Although biological theories are the foundation of biological forces, the full picture of how and why we age cannot be understood without considering the other three forces (psychological, sociocultural, and life cycle).
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PHYSICAL CHANGES 89
dioxide decrease with age. Declines in the maxi- mum amount of air we can take in also occur.
Chronic obstructive pulmonary disease (COPD), such as emphysema, increases with age. Emphy- sema is the most common form of age-related COPD; although most cases are caused by smoking, a few are caused by secondhand smoke, air pol- lution, or genetic factors. Chronic bronchitis also becomes more prevalent with age.
3.5 The Reproductive System
What reproductive changes occur in women? The transition from childbearing years to the
cessation of ovulation is called the climacteric; menopause is the point at which the ovaries stop releasing eggs. A variety of physical and psycho- logical symptoms accompany menopause (e.g., hot flashes), including several in the genital organs; however, women in some cultures report different experiences.
Menopausal hormone therapy remains controver- sial because of conflicting results about its long- term effects.
No changes occur in the desire to have sex; how- ever, the availability of a suitable partner for women is a major barrier.
What reproductive changes occur in men? In men, sperm production declines gradually with
age. Changes in the prostate gland occur and should be monitored through yearly examinations.
Some changes in sexual performance, such as increased time to erection and ejaculation and increased refractory period, are typical.
What are the psychological implications of age-related changes in the reproductive system?
Healthy adults of any age are capable of engaging in sexual activity, and the desire to do so does not diminish with age. However, societal stereotyping creates barriers to free expression of such feelings.
3.6 The Autonomic Nervous System
What major changes occur in the autonomic nervous system?
Regulating body temperature becomes increas- ingly problematic with age. Older adults have dif- ficulty telling when their core body temperature
How does hearing change as people age? Age-related declines in the ability to hear high-
pitched tones (presbycusis) are normative. Exposure to noise speeds up and exacerbates hear-
ing loss. Psychologically, hearing losses can reduce the abil-
ity to have satisfactory communication with others.
What age-related changes occur in people’s senses of touch and balance?
Changes in sensitivity to touch, temperature, and pain are complex and not understood; age-related trends are unclear in most cases.
Dizziness and vertigo are common in older adults and increase with age, as do falls. Changes in balance may result in greater caution in older adults when walking.
What happens to taste and smell with increasing age? Age-related changes in taste are minimal. Many
older adults complain about boring food; however, these complaints appear to be largely unrelated to changes in taste ability.
The ability to detect odors declines rapidly after age 60 in most people. Changes in smell are primar- ily responsible for reported changes in food prefer- ence and enjoyment.
3.4 Vital Functions
What age-related changes occur in the cardiovascular system?
Some fat deposits in and around the heart and inside arteries are a normal part of aging. Heart muscle gradually is replaced with stiffer connec- tive tissue. The most important change in the cir- culatory system is the stiffening (hardening) of the walls of the arteries.
Overall, men have a higher rate of cardiovascu- lar disease than women. Several diseases increase in frequency with age: congestive heart failure, angina pectoris, myocardial infarction, atheroscle- rosis (severe buildup of fat inside and the calcifica- tion of the arterial walls), cerebrovascular disease (cardiovascular disease in the brain), and hyperten- sion (high blood pressure).
What structural and functional changes occur with age in the respiratory system?
The amount of air we can take into our lungs and our ability to exchange oxygen and carbon
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90 CHAPTER 3
noted? Which cardiovascular diseases increase in frequency with age?
What changes occur with age in the respiratory sys- tem? How are respiratory diseases related to age?
3.5 The Reproductive System What age-related nges occur in women’s and men’s
reproductive ability? How does interest in sexual activity change with
age? What constraints operate on men and women?
3.6 The Nervous System What changes occur in people’s ability to regulate
body temperature? How does sleep change with age?
INTEGRATING CONCEPTS IN DEVELOPMENT How do the various biological theories of aging
match with the major age-related changes in body systems? Which theories do the best job? Why?
Given what you now know about normative changes in appearance, what would you say about the ste- reotypes of aging you identified in the Discovering Development exercise you did in Chapter 1 ?
Why do you think the rates of death from cardio- vascular disease are so much higher in industrial- ized countries than elsewhere?
How might the age-related changes in the respira- tory system be linked with societal policies on the environment?
KEY TERMS angina pectoris A painful condition caused by tempo- rary constriction of blood flow to the heart.
atherosclerosis A process by which fat is deposited on the walls of arteries.
cataracts Opaque spots on the lens of the eye.
cerebrovascular accident (CVA), An interruption of the blood flow in the brain.
chronic obstructive pulmonary disease (COPD), A fam- ily of age-related lung diseases that block the passage of air and cause abnormalities inside the lungs.
climacteric The transition during which a woman’s reproductive capacity ends and ovulation stops.
drops, and their vasoconstrictor response dimin- ishes. When they become very hot, older adults are less likely than are younger adults to drink the water they need.
Sleep patterns and circadian rhythms change with age. Older adults are more likely to compensate by taking daytime naps, which exacerbates the problem. Effective treatments include exercising, reducing caffeine, avoiding daytime naps, and making the sleep environment as quiet and dark as possible.
What are the psychological implications of changes in the brain?
Maintaining body temperature is essential to good health. Getting good sleep is also important for good functioning.
Review Questions 3.1 Why Do We Age? Biological Theories of Aging
What biological theories have been proposed to explain aging? What are their similarities and differences?
Why do some people argue that diets high in anti- oxidants can prolong life?
What are some of the sociocultural forces that operate on the biological theories? What are some examples of these forces?
3.2 Appearance and Mobility What age-related changes occur in appearance? How does body build change with age? How do muscle and bone tissue change with age?
3.3 Sensory Systems What age-related changes occur in vision? What
are the psychological effects of these changes? What age-related changes occur in hearing? What
are the psychological effects of these changes? What age-related changes occur in somesthesia
and balance? What age-related changes occur in taste and smell?
3.4 Vital Functions What changes occur with age in the cardiovascu-
lar system? What gender differences have been
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PHYSICAL CHANGES 91
osteoarthritis, A form of rthritis marked by gradual onset and progression of pain and swelling, caused primarily by overuse of a joint.
osteoporosis, A degenerative bone disease more common in women in which bone tissue deteriorates severely to produce honeycomb-like bone tissue.
perimenopause The time of transition from regular menstruation to menopause.
presbycusis, A normative age-related loss of the abil- ity to hear high-pitched tones.
presbyopia The normative age-related loss of the abil- ity to focus on nearby objects, usually resulting in the need for glasses.
rheumatoid arthritis, A destructive form of arthri- tis involving more swelling and more joints than osteoarthritis.
telomerase An enzyme needed in DNA replication to fully reproduce the telomeres when cells divide.
telomeres, Tips of the chromosomes that shorten with each replication.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
congestive heart failure A condition occurring when cardiac output and the ability of the heart to contract severely decline, making the heart enlarge, increasing pressure to the veins, and making the body swell.
cross-linking Random interaction between pro- teins that produce molecules that make the body stiffer.
emphysema Severe lung disease that greatly reduces the ability to exchange carbon dioxide for oxygen.
free radicals, Deleterious and short-lived chemicals that cause changes in cells that are thought to result in aging.
glaucoma, A condition in the eye caused by abnormal drainage of fluid.
hypertension A disease in which one’s blood pressure is too high.
menopausal hormone therapy (MHT) Low doses of estrogen, which is often combined with progestin (synthetic form of progesterone) taken to counter the effects of declining estrogen levels.
menopause The cessation of the release of eggs by the ovaries.
myocardial infarction (MI), A heart attack.
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Longevity, Health, and Functioning
4.1 HOW LONG WILL WE LIVE? Discovering Development: Take the Longevity Test • Average and Maximum Longevity • Genetic and Environmental Factors in Average Longevity • Ethnic Differences in Average Longevity • Gender Differences in Average Longevity • International Differences in Average Longevity
4.2 HEALTH AND ILLNESS Defining Health and Illness • Quality of Life • Changes in the Immune System • Chronic and Acute Diseases • The Role of Stress • How Do We Know?: Negative Life Events and Mastery
4.3 COMMON CHRONIC CONDITIONS AND THEIR MANAGEMENT General Issues in Chronic Conditions • Common Chronic Conditions • Current Controversies: The Prostate Cancer Dilemma • Managing Pain
4.4 PHARMACOLOGY AND MEDICATION ADHERENCE Patterns of Medication Use • Developmental Changes in How Medications Work • Medication Side Effects and Interactions • Adherence to Medication Regimens
4.5 FUNCTIONAL HEALTH AND DISABILITY A Model of Disability in Late Life • Determining Functional Health Status • What Causes Functional Limitations and Disability in Older Adults?
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 4
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LONGEVITY, HEALTH, AND FUNCTIONING 93
Jeanne Calment was one of the most important people to ever live. Her amaz- ing achievement was not made in sports, govern- ment, or any other profession. When she died in 1996 at age 122 years and 164 days, she set the world record for the longest verified human life span. Jeanne lived her entire life in Arles, France. During her lifetime, she met Vincent Van Gogh, experienced the invention of the lightbulb, auto- mobiles, airplanes, space travel, computers, and all sorts of everyday conveniences. She survived two world wars. Longevity ran in her family: Her older brother, François, lived to the age of 97 , her father to 93 , and her mother to 86 . Jeanne was extraordinarily healthy her whole life, rarely being ill. She was also active; she learned fenc- ing when she was 85 , and still rode a bicycle at age 100 . She lived on her own until she was 110 , when she moved to a nursing home. Her life was documented in the 1995 film Beyond 120 Years with Jeanne Calment . Shortly before her 121 st birthday, Musicdisc released Time’s Mistress , a CD of Jeanne speaking over a background of rap and hip-hop music.
Did you ever wonder how long you would like to live? Would you like to live to be as old as Jeanne Calment? Scientific advances are happen- ing so quickly in our understanding of the factors that influence longevity, many scientists think that numerous, perhaps most people could live to 120 years. Indeed, the May 2013 issue of National Geo- graphic magazine devoted its main feature to the
possibility the baby on the front cover and many of its peers would live to 120 years (or longer). Let’s take a closer look at what we know about human longevity
4.1 How Long Will We Live? LEARNING OBJECTIVES
What is the average and the maximum longevity for humans?
What genetic and environmental factors influence longevity?
What ethnic factors influence average longevity? What factors create gender differences in average
longevity
Susie is a 51 -year-old Chinese American living in San Francisco. Susie’s mother (age 76 ), father (age 77 ), and grandmother (age 103 ), who are all in excellent health, live with her and her husband. Susie knows that sev- eral of her other relatives have lived long lives, but she wonders whether this has any bearing on her own life expectancy.
As we saw in Chapter 1 , many more people are living to old age today than ever before. Like Susie, people today have already seen far more older adults than their great-great-grandparents ever saw. The tre- mendous increase in the number of older adults has focused renewed interest in how long you may live. Susie’s question about her own longevity exemplifies this interest. Knowing how long we are likely to live is important not only for us but also for government agencies, service programs, the business world, and insurance companies. Why? The length of life has an enormous impact on just about every aspect of life, from decisions about government health care pro- grams (how much money should Congress allocate to Medicare?) to retirement policy (debates over the age at which people may collect maximum retirement benefits) to life insurance premiums (longer lives on average mean cheaper rates for young adults because they are now healthier for longer periods of their lives). Longer lives have forced changes in all these areas and will continue to do so for the next several decades.
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94 CHAPTER 4
Life expectancy can be examined from the per- spective of the basic developmental forces, because how long we live depends on complex interactions among biological, psychological, socioeconomic, and life-cycle forces. For example, some people, like Susie, have many relatives who live to very old age, whereas others have relatives who die young. Tendencies toward long lives (or short ones, for that matter) tend to run in families. As you will see, our “long-life genes” play a major role in governing how long we are likely to live.
But the world in which we live can affect how long we live, too. Environmental factors such as dis- ease and toxic chemicals modify our genetic heritage and shorten our lifetime, sometimes drastically. By the same token, environmental factors such as access to high-quality medical care can sometimes offset genetic defects that would otherwise have caused early death, thereby increasing our longevity. In short, no single developmental force can account for the length of life. Let’s begin by exploring the concept of longevity. To get started, complete the exercise in the Discovering Development feature and see how long you might live. When you have finished, continue reading to discover the research base behind the numbers.
Average and Maximum Longevity How long you live, called longevity, is jointly deter- mined by genetic and environmental factors. Researchers distinguish between two different types of longevity: average longevity and maximum lon- gevity. Average longevity is commonly called average life expectancy and refers to the age at which half of the individuals who are born in a particular year will have
died. Average longevity is affected by both genetic and environmental factors.
Average longevity can be computed for people at any age. The most common method is to compute average longevity at birth, which is the projected age at which half of the people born in a certain year will have died. This computation takes into account people who die at any age, from infancy onward. The current average longevity is about 79 years at birth for peo- ple in the United States (National Center for Health Statistics, 2012a). This means that 79 years after a group of people are born, half of them will still be alive. When average longevity is computed at other points in the life span, the calculation is based on all the people who are alive at that age; people who died earlier are not included. For example, computing the average longevity for people currently 65 years old would pro- vide a predicted age at which half of those people will have died. People who were born into the same birth cohort but who died before age 65 are not counted. Eliminating those who die at early ages from the com- putation of average longevity at a specific age makes projected average longevity at age 65 longer than it was at birth. In the United States, females currently aged 65 can expect to live on average about 20 more years; men about 18 more years.
For people in the United States, average longevity has been increasing steadily since 1900; recent esti- mates for longevity at birth and at age 65 are presented in Figure 4.1 . Note in the figure that the most rapid increases in average longevity at birth occurred in the first half of the 20 th century. These increases in aver- age longevity were caused mostly by declines in infant mortality rates, brought about by eliminating diseases such as smallpox and polio and through better health care. The decrease in the number of women who died during childbirth was especially important in rais- ing average life expectancies for women. Advances in medical technology and improvements in health care mean that more people survive to old age, thereby increasing average longevity in the general population.
Maximum longevity is the oldest age to which any individual of a species lives. Although the biblical char- acter Methuselah is said to have lived to the ripe old age of 969 years, modern scientists are more conser- vative in their estimates of a human’s maximum lon- gevity. Even if we were able to eliminate all diseases,
DISCOVERING DEVELOPMENT: TAKE THE LONGEVITY TEST Did you ever speculate about how long you might live? Are you curious? If you’d like a preview of sev- eral of the key influences on how long we live, try completing the questions at http://www.livingto100 .com . Take notes about why you think each question is being asked. Once you’re finished, submit your form. Take time to read about each of the topics, then read more about them in the text. Will you live to be 100 ? Only time will tell!
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LONGEVITY, HEALTH, AND FUNCTIONING 95
most researchers estimate the limit to be somewhere around 120 years because key body systems such as the cardiovascular system have limits on how long they can last (Hayflick, 1998). Genetic theories also place the human limit around 120 years (Barja, 2008; Rattan, 2012). The world record for longevity that can be veri- fied by birth records was held by Jeanne Calment of France, who died in 1997 at age 122 years.
It remains to be seen whether maximum longev- ity will change as new technologies produce better artificial organs and health care. An important issue is whether extending the life span indefinitely would be a good idea. Because maximum longevity of differ- ent animal species varies widely (Barja, 2008; Rattan, 2012), scientists have tried to understand these differ- ences by considering important biological functions such as metabolic rate or various changes at the molec- ular level (Rattan, 2012). But no one has figured out how to predict longevity. For example, why the giant tortoises of the Galapagos Islands typically live longer than we do remains a mystery.
Increasingly, researchers are differentiating bet- ween active life expectancy and dependent life expec- tancy; the difference is between living to a healthy old age (active life expectancy) and simply living a long time (dependent life expectancy). Said another way, it is the
difference between adding years to life and adding life to years. One’s active life expectancy ends at the point when one loses independence or must rely on others for most activities of daily living (e.g., cooking meals, bathing). The remaining years of one’s life constitute living in a dependent state. How many active and dependent years one has in late life depends a great deal on the interaction of genetic and environmental factors, to which we now turn.
Genetic and Environmental Factors in Average Longevity
Let’s return to Susie, who wonders whether she can expect to live a long life. What influences how long we will live on average? Our average longevity is influenced most by genetic, environmental, ethnic, and gender factors. Clearly, these factors interact; being from an ethnic minority group or being poor, for example, often means that one has a higher risk of exposure to a harmful environment and less access to high-quality health care. But it is important to examine each of these factors and see how they influence our longevity. Let’s begin with genetic and environmental factors.
Genetic Factors. Living a long life has a clear, but complex, genetic link. We have known for a long time that a good way to have a greater chance of a long life
Figure 4.1 Average longevity for men and women in the United States 1900–2009. Source: Data from Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System (2008). © 2015 Cengage Learning
1900 0
20
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100
Life expectancy at 65 years
Life expectancy at birth
Female
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1910 1920 1930 1940 1950 Year
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ea rs
1960 1970 1980 1990 2000 2010
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96 CHAPTER 4
is to come from a family with a history of long-lived individuals. Alexander Graham Bell (the same guy who received the credit for inventing the telephone) was one of the first people to demonstrate systematically the ben- efits of coming from a long-lived family. Bell considered 8,797 of William Hyde’s descendants and found that children of parents who had lived beyond 80 survived about 20 years longer than children whose parents had both died before they were 60 . Thus Susie’s long-lived family sets the stage for Susie to enjoy a long life herself.
One exciting line of contemporary research, the Human Genome Project, completed in 2003, has mapped all our genes. This research and its spinoffs in microbiology and behavior genetics are continuing to produce astounding results in terms of genetic linkages to disease and aging (you can track these through the main website of the Project).
Based on this gene mapping work, attempts are being made to treat diseases by improving the way that medications work and even by implanting “corrected” genes into people in the hope that the good genes will in some cases reproduce and eventually wipe out the defective genes, and in others prevent the shortening of telomeres (discussed in Chapter 3 ; Boccardi & Herbig, 2012; Kanehisa et al., 2008). Payoffs from such research are helping us understand how increasing numbers of people are living to 100 or older. For example, research on people over age 100 (centenarians) in Sicily showed a connection between genetics and the immune system (Balistreri, Candore, Accardi, Bova, Buffa, Bulati et al., 2012). The oldest-old, such as Suzie’s grandmother, are hardy because they have a high threshold for disease and show slower rates of disease progression than their peers who develop chronic diseases at younger ages and die earlier.
Environmental Factors. Although genes are a major determinant of longevity, environmental fac- tors also affect the life span, often in combination with genes (Rando & Chang, 2012). Some environmental factors are more obvious; diseases, toxins, lifestyle, and social class are among the most important. Diseases, such as cardiovascular disease and Alzheimer’s dis- ease, and lifestyle issues, such as smoking and exer- cise, receive a great deal of attention from research- ers. Environmental toxins, encountered mainly as air and water pollution, are a continuing problem. For example, toxins in fish, bacteria, and cancer-causing
chemicals in drinking water, and airborne pollutants are major agents in shortening longevity.
Living in poverty shortens longevity. The impact of socioeconomic status on longevity results from reduced access to goods and services, especially medi- cal care and diet, that characterizes most ethnic minor- ity groups, the poor, and many older adults (Doubeni, Schootman, Major, Torres Stone, Laiyemo, Park et al., 2012). Most of these people have little or no health insurance, cannot access good health care, and cannot afford healthy food. For many living in urban areas, air pollution, poor drinking water, and lead poisoning from old water pipes are serious problems, but they simply cannot afford to move. Although longevity dif- ferences between high and low socioeconomic groups in the United States narrowed during the latter part of the 20 th century, these improvements have stopped since 1990 due to continued differences in access to health care (Swanson & Sanford, 2012).
How environmental factors influence average life expectancy changes over time. For example, acquired immunodeficiency syndrome (AIDS) has had a dev- astating effect on life expectancy in Africa, where in some countries (e.g., Botswana, Namibia, South Africa, Zimbabwe) average longevity may have been reduced by as much as 30 years from otherwise expected levels (Kinsella & Phillips, 2005). In contrast, negative effects of cardiovascular diseases on average longevity are lessening as the rates of those diseases decline in many developed countries (National Center for Health Statistics, 2012a).
The sad part about most environmental factors is that we are responsible for most of them. Denying adequate health care to everyone, continuing to pollute our environment, and failing to address the underly- ing causes of poverty have undeniable consequences: These causes needlessly shorten lives and dramatically increase the cost of health care.
Ethnic Differences in Average Longevity People in different ethnic groups do not have the same average longevity at birth. For example, although Afri- can Americans’ average life expectancy at birth is about 6 years less for men and about 4 years less for women than it is for European Americans, by age 65 this gap has narrowed to about 2 and 1.5 years, respectively, for men and women. By age 85 , African Americans tend to outlive European Americans. Why the shift over time?
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LONGEVITY, HEALTH, AND FUNCTIONING 97
Lower access to good-quality health care in general means that those African Americans who live to age 85 tend to be in better health on average than their European American counterparts. But this is just a guess. Latinos have higher average life expectancies than European Americans and African Americans at all ages despite hav- ing, on average, less access to health care (National Center for Health Statistics, 2012a). The full explanation for these ethnic group differences remains to be discovered.
Gender Differences in Average Longevity Have you ever visited a senior center or a nursing home? If so, you may have asked yourself, “Where are all the very old men?” Women’s average longevity is about 5 years more than men’s at birth, narrowing to roughly 1 year by age 85 (National Center for Health Statistics, 2012b). These differences are fairly typical of most industrialized countries but not of developing countries. In fact, the female advantage in average lon- gevity in the United States became apparent only in the early 20 th century (Hayflick, 1996). Why? Until then, so many women died in childbirth that their average longevity as a group was no more than that of men. Death in childbirth still partially explains the lack of a female advantage in developing countries today; how- ever, another part of the difference in some countries results from infanticide of baby girls. In industrial- ized countries, socioeconomic factors such as access to health care and improved lifestyle factors also help account for the emergence of the female advantage.
Many ideas have been offered to explain the sig- nificant advantage women have over men in average longevity in industrialized countries, and that emerg- ing in developing countries (Roy, Punhani, & Shi, 2012). Overall, men’s rates of dying from the top 15 causes of death are significantly higher than women’s at nearly every age, and men are also more susceptible to infectious diseases. These differences have led some to speculate that perhaps it is not just a gender-related biological difference at work in longevity, but a more complex interaction of lifestyle, improved health care, greater susceptibility in men of contracting certain fatal diseases and dying prematurely (e.g., in war or through accidents at work), and genetics.
Other researchers disagree; they argue that there are potential biological explanations. These include the fact that women have two X chromosomes, compared with one in men; men have a higher metabolic rate; women have a higher brain-to-body weight ratio; and women have lower testosterone levels. However, none of these explanations has sufficient scientific support to explain why most women in industrialized countries can expect, on average, to outlive most men (Roy et al., 2012).
Despite their longer average longevity, women do not have all the advantages. Interestingly, older men who survive beyond age 90 are the hardiest segment of their birth cohort in terms of performance on cogni- tive tests (Perls & Terry, 2003). Between ages 65 and 89 , women score higher on cognitive tests; beyond age 90 , men do much better.
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98 CHAPTER 4
International Differences in Average Longevity
Countries around the world differ dramatically in how long their populations live on average. As you can see in Figure 4.2 , the current range extends from 38 years
in Sierra Leone in Africa to over 82 years in Japan. Such a wide divergence in life expectancy reflects vast discrepancies in genetic, sociocultural and economic conditions, health care, disease, and the like across industrialized and developing nations.
More than 74 years
70–74
65–69
60–64
55–59
50–54
45–49
Less than 45 years
Life expectancy at birth in selected countries, 2008
Australia 81.5
Mexico 75.8
South Africa 48.9
Argentina 76.4
Uganda 52.3
Egypt 71.8
Afghanistan 44.2
Kenya 56.6
Iraq 69.6
Indonesia 70.5
Japan 82.1
Israel 80.6
Turkey 73.1
Germany 79.1
Italy 80.1
Philippines 70.8
Venezuela 73.5
Honduras 69.4
Bolivia 66.5
United States 78.1
India 69.2
China 73.2
Russia 65.9
Sierra Leone 38.0
Cuba 77.3
Figure 4.2 International data on life expectancy at birth. Note the differences between developed and developing countries. Source: From International programs: International data base, by U.S. Census Bureau. Copyright © U.S. Census Bureau 2010.www.census.gov/ipc/ www/idb /tables.html
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LONGEVITY, HEALTH, AND FUNCTIONING 99
4.2 Health and Illness LEARNING OBJECTIVES
What are the key issues in defining health and illness?
How is quality of life assessed? What normative age-related changes occur in the
immune system? What are the developmental trends in chronic and
acute diseases? What are the key issues in stress across
adulthood?
Rosa is a 72 -year-old immigrant from Mexico, living in a small apartment in a large city in the southwest- ern United States. For most of her life she has been very healthy, but lately she has noticed it is getting harder to get up every morning. In addition, when she gets a cold, she takes longer to recover than when she was younger. Rosa wonders whether these problems are typical or whether she is experiencing something unusual.
Each of us has had periods of health and of illness. Most people are like Rosa—healthy for nearly all our lives. In this section, we will tackle the difficult issue of defining health and illness. We will consider quality of life, an increasingly important notion as medical tech- nology keeps people alive longer. We will see how the differences between acute and chronic disease become more important with age. Because our immune system plays such a central role in health and illness, we will examine key age-related changes in it. Finally, we will consider how stress can affect our health.
Defining Health and Illness What does the term health mean to you? Total lack of disease? Complete physical, mental, and social well- being? Actually, scientists cannot agree on a compre- hensive definition, largely because the term has been
used in so many different contexts (Davies, 2007; Ogden, 2012). Many people now include biological, psychological, sociocultural, spiritual, and environmen- tal components; as Davies (2007) puts it, health is an ongoing outcome from the processes of a life lived well.
The World Health Organization defines health as a state of complete physical, mental, and social well- being, and not merely the absence of disease or infirmity (World Health Organization, 2007). Illness is the pres- ence of a physical or mental disease or impairment.
Think for a moment about your health. How would you rate it? Although this question looks sim- ple, how people answer it turns out to be predictive of illness and mortality (Longest & Thoits, 2012). Why? There are several possibilities (Wolinsky & Tierney, 1998). One is that self-rated health captures more aspects of health than other measures. A second pos- sibility is that poor self-rated health reflects respon- dents’ belief that they are on a downward trajectory in functioning. A third is that people’s self-ratings affect their health-related behaviors, which in turn affect health outcomes. Finally, self-rated health may actu- ally represent an assessment of people’s internal and external resources that are available to support health. Research data support all these ideas; a review of more than 30 years of research has shown that self-ratings of health are very predictive of future health outcomes (Blazer, 2008).
Self-ratings also tend to be fairly stable over time. Wolinsky and colleagues (2008) followed 998 African Americans aged 49 to 65 for 4 years, and found that 55 % had the same self-rating over time ( 25 % improved and 20 % declined). Even factoring in change in rat- ings does not improve the ability to predict mortal- ity compared to a standard single indicator of health (Galenkamp, Deeg, Braam, & Huisman, in press). Overall, men rated their health worse than women did. Among the oldest-old, self-rated health is a powerful predictor of mortality across cultures; for example, a two-year study in China showed that self-rated health still predicted mortality even after socioeconomic status and health conditions had been accounted for (Chen & Wu, 2008). Similar results were obtained for men in India (Hirve, Juvekar, Sambhudas, Lele, Blomstedt, Wall et al., in press).
However, self-ratings of health do reflect differ- ences in socioeconomic background in terms of how
Adult Development in Action Suppose you are a financial planner for people who want to save for their retirement. Given what you have learned about longevity, how would you advise people in their 40 s in terms of savings?
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100 CHAPTER 4
healthy people say they are. For example, indigenous Australians rate their health as significantly poorer than nonindigenous Australians, mainly due to dif- ferences in economic variables (e.g., access to health care) (Booth & Carroll, 2008). In the United States, African Americas are twice as likely, and Mexican Americans and Puerto Rican Americans three times more likely, to self-report their health as fair or poor than European Americans (Benjamins, Hirschman, Hirschtick, & Whitman, 2012).
Overall, given the strong relation between self- rated health and actual health-related outcomes, including one’s own mortality, it should come as no surprise that researchers often include such measures in their studies of older adults. Such measures provide a good proxy (or stand-in) variable for health, avoiding a time-consuming (and possibly costly) assessment of health. This approach works most of the time; as we proceed, the times when it doesn’t will be noted.
Quality of Life We’ll bet if you asked most people what they want out of life, they would say something about a good quality of life. But what does that mean? Precise definitions are hard to find. Sometimes people find it easier to say what quality of life is not: being dependent on a respi- rator while in a permanent vegetative state is one com- mon example. Researchers, though, like to be more specific. They tend to look at several specific aspects of quality of life: health-related quality of life and non- health-related quality of life. Health-related quality of life includes all of the aspects of life that are affected by changes in one’s health status. Non-health-related quality of life refers to things in the environment, such as entertainment, economic resources, arts, and so on that can affect our overall experience and enjoyment in life.
Most research on quality of life has focused on two areas: quality of life in the context of specific diseases or conditions and quality of life relating to end-of-life issues. We briefly lay out the issues here. We will return to them as we discuss specific situations in this chapter and in Chapters 5 (interventions that increase quality of life) and 13 (end-of-life issues).
In many respects, quality of life is a subjec- tive judgment that can be understood in the context of broader models of adult development and aging.
One such model describes ways in which people select domains of relative strength, optimize their use of these strengths, and compensate for age-related changes (Baltes et al., 2006). In addition, one must also consider not only the physical health aspects but also mental health and the person’s life situation in assess- ing quality of life (Brett, Gow, Corley, Pattie, Starr, & Deary, 2012). From this perspective, quality of life is a successful use of the selection, optimization, and com- pensation model (SOC) to manage one’s life, resulting in successful aging. Applying this approach to research in health care, quality of life refers to people’s percep- tions of their position in life in context of their cul- ture (Karim et al., 2008) and in relation to their goals, expectations, values, and concerns (Brett et al., 2012).
In general, research on health-related quality of life addresses a critical question (Lawton et al., 1999): To what extent does distress from illness or side effects associated with treatment reduce a person’s wish to live? Lawton and colleagues (1999) set the standard for answering this question by showing that it depends a great deal on a person’s valuation of life, the degree to which a person is attached to his or her present life. How much one enjoys life, has hope about the future, and finds meaning in everyday events, for example, have a great deal of impact on how long that person would like to live.
Narrowing the focus of the quality-of-life con- cept as it relates to specific conditions brings us to the domains of physical impairment or disability and of dementia. Quality of life in the former context includes issues of environmental design that improve people’s functioning and well-being, such as handi- capped accessible bathrooms and facilities (Pynoos, Caraviello, & Cicero, 2010). We examine environmen- tal influences in Chapter 5 .
Quality of life is more difficult to assess in people with dementia and chronic diseases, although new assessment instruments have been developed (Karim et al., 2008; Skevington & McCrate, 2012). We consider this issue in more detail in Chapter 10 when we focus on Alzheimer’s disease.
Changes in the Immune System Every day, our bodies are threatened by invaders: bacte- rial, viral, and parasitic infections (as well as their toxic by-products) and abnormal cells such as precancerous
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LONGEVITY, HEALTH, AND FUNCTIONING 101
and tumor cells. Fortunately for us, we have a highly advanced defense system against foreign invaders: the immune system. The National Cancer Institute pro- vides a Web-based overview of how our immune sys- tem works; check it out to learn how sophisticated our defense system is.
Many details of how our immune system works remain unknown. For instance, one great mystery is how the immune system learns to differentiate your own cells from invaders. Researchers think the mecha- nism involves recognizing certain substances, called antigens , on the surface of invading bacteria and cells that have been taken over by viruses. Regardless of how this actually happens, once the immune system has learned to recognize the invader, it creates a defense against that invader.
How does this defense system work? It’s an amazing process that is based essentially on only three major types of cells, which form a network of interacting parts (Mak & Saunders, 2014): cell-mediated immunity (consisting of cells originating in the thymus gland, or T-lymphocytes ), immunity based on the release of antibodies in the blood, such as those manufactured in bone marrow or acquired from immunization or previous infection ( B-lymphocytes ), and nonspecific immunity ( monocytes and polymorphonuclear neutrophil leukocytes ).
The primary job of the T- and B-lymphocytes is to defend against malignant (cancerous) cells, viral infec- tion, fungal infection, and some bacteria. Natural killer (NK) cells are another, special type of lymphocytes that monitor our bodies to prevent tumor growth. These are our primary defense against cancer, although how this happens is not fully understood. NK cells also help fight viral infections and parasites. In addition, there are five major types of specialized antibodies called immuno- globulins (IgA, IgD, IgE, IgG, and IgM). For example, IgM includes the “first responders” in the immune sys- tem, IgE is involved in allergies and asthma, and IgG (also called g-globulin) helps fight hepatitis.
How does aging affect the immune system? Researchers are only beginning to understand this pro- cess, and there are large gaps in the literature (Mak & Saunders, 2014). Moreover, the immune system is sen- sitive to a wide variety of lifestyle and environmental factors, such as diet, stress, exercise, and disease, mak- ing it very difficult to isolate changes caused by aging alone (Effros, 2012; Goldstein, 2012).
Changes in health with age provide insights into immune functioning. Older adults are more suscep- tible to certain infections and have a much higher risk of cancer (both of which are discussed in more detail later in this chapter), so most researchers believe that the immune system changes with age. Indeed, NK cells and several other aspects of the immune system decrease in effectiveness with age (Effros, 2012). For one thing, older adults’ immune systems take longer to build up defenses against specific diseases, even after an immunization injection. This is probably caused by the changing balance in T-lymphocytes and may par- tially explain why older adults need to be immunized earlier against specific diseases such as influenza.
Similarly, B-lymphocytes decrease in function- ing. Research examining the administration of sub- stances such as growth hormones to older adults to stimulate lymphocyte functioning indicates that some specific lymphocyte functioning returns to normal with treatment, and can regenerate the thymus gland, both of which are important in treating individuals with HIV (Chidgey, 2008). This process for T- and B-lymphocytes is described in Figure 4.3 .
Young thymus Thymosin production T-cell lymphocytes
Old thymus Decreased thymosin production Decreased T-cell function
Thymus involutes between ages 12 and 35
Decreased defense against viruses Monocellular and multicellular organisms
Decreased B-cell function causing Decreased antibodies Failure of self-regulation Increased autoantibodies
Figure 4.3 Process of aging of the immune system. Source: Reprinted with permission from Ebersole, P., & Hess, P., Toward Healthy Aging (5e, p. 41). Copyright © 1998 Mosby St. Louis: with permission from Elsevier. © 2015 Cengage Learning
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102 CHAPTER 4
Changes in immune system function have impor- tant implications (Effros, 2012; Goldstein, 2012). Older adults become more prone to serious consequences from illnesses—such as those caused by viruses—that are easily defeated by younger adults. Older adults also benefit less from immunizations. In addition, various forms of leukemia, which are cancers of the immune cells, increase with age, along with other forms of cancer. Finally, the immune system can begin attack- ing the body itself in a process called autoimmunity. Autoimmunity results from an imbalance of B- and T-lymphocytes, giving rise to autoantibodies, and is responsible for several disorders, such as rheumatoid arthritis (Goronzy & Weyand, 2012).
A growing body of evidence is pointing to key con- nections between our immune system and our psycho- logical state. Over 20 years of research shows how our psychological state, or a characteristic such as our atti- tude, creates neurological, hormonal, and behavioral responses that directly change the immune system and make us more likely to become ill (Segerstrom, 2012). Psychoneuroimmunology is the study of the relations between psychological, neurological, and immunological systems that raise or lower our susceptibility to and abil- ity to recover from disease.
Psychoneuroimmunology is increasingly being used as a framework to understand health outcomes and in predicting how people cope with and survive illness (Irwin, 2008; Yan, 2012). By considering the various factors influencing disease, interventions that optimally combine medication, diet, and mind-body strategies (e.g., meditation) can be devised.
HIV/AIDS and Older Adults. An increasing number of older adults have HIV/AIDS (HIV is the virus that causes the disease AIDS); the Administration on Aging (2012b) estimates that in the United States roughly 1.2 million people in the United States have HIV. By 2015, it is expected that about half of the peo- ple in the United States with HIV will be over age 50 . Unfortunately, because of the social stereotype that older adults are not sexually active, many physicians do not test older patients; however, as HIV/AIDS rates increase among older adults, the importance of testing is being emphasized (Longo et al., 2008).
Although older men are at higher risk for AIDS, older women also are at significant risk. For men, the most common risk factor is homosexual or bisexual
behavior. In contrast, AIDS usually is transmitted to older women through heterosexual contact with infected partners. Older adults may be more suscep- tible to HIV infection because of the changes in the immune system discussed earlier. For women, the thin- ning of the vaginal wall with age makes it more likely that it will tear, making it easier for the HIV to enter the bloodstream. Older adults may believe that con- dom use is no longer necessary, which also raises the risk (Tangredi et al., 2008). Older African Americans are 12 times more likely than their European American counterparts to have HIV, and Latinos are five times more likely (Gay Men’s Health Crisis, 2010).
Once they are infected, the progression from HIV- positive status to AIDS is more rapid among older adults due to the changes in the immune system with age described earlier (Gay Men’s Health Crisis, 2010). Once they are diagnosed with AIDS, older adults’ remaining life span is significantly shorter than it is for newly diagnosed young adults, and mortality rates are higher.
Clearly, older adults need to be educated about their risk for HIV and AIDS, and about the continued need for condom use. However, ageism on the part of professionals, misconceptions about sexual activity among older adults, and older adults’ lack of knowledge concerning HIV/AIDS are all barriers (Milaszewski, Greto, Klochkov, & Fuller-Thomson, 2012). Few media stories about the problem focus on older adults, who thus may mistakenly believe they have nothing to worry about. They are less likely to raise the issue with a physician, less likely to be tested, and, if diagnosed, less likely to seek support groups. In short, we need to change outmoded beliefs about older adults and sexu- ality and focus on health and prevention.
Chronic and Acute Diseases Rosa, the immigrant from Mexico, is typical of older adults: She is beginning to experience some recur- ring health difficulties and is finding out that she does not recover as quickly from even minor afflic- tions. You probably have had several encounters with illnesses that come on quickly, may range from mild to very severe, last a few days, and then go away. Ill- nesses such as influenza and strep throat are examples. You also may have experienced conditions that come on more slowly, last much longer, and have long-term
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LONGEVITY, HEALTH, AND FUNCTIONING 103
consequences. Kidney disease, diabetes, and arthritis are examples. Your experiences reflect the difference between acute and chronic diseases.
Acute diseases are conditions that develop over a short period of time and cause a rapid change in health. We are all familiar with acute diseases, such as colds, influenza, and food poisoning. Most acute diseases are cured with medications (such as antibiotics for bac- terial infections) or allowed to run their course (the case with most viral infections). In contrast, chronic diseases are conditions that last a longer period of time (at least 3 months) and may be accompanied by residual functional impairment that necessitates long-term man- agement. Chronic diseases include arthritis and diabe- tes mellitus.
What do you think happens to the incidence of acute and chronic diseases as people age? If you say that the rates of acute diseases go down whereas the rates of chronic diseases go up, you are correct. Contrary to what many people believe, older adults have fewer colds, for example, than younger adults. However, when they do get an acute disease, older adults tend to get sicker; recovery takes longer; and death from acute disease occurs more often (Centers for Disease Control and Prevention, 2012e). Thus, although they get fewer acute infections, older people may actually spend more days feeling sick than their younger (and, based on fre- quency of occurrence, “sicker”) counterparts.
This is probably why many people mistakenly believe that the rates of acute disease increase with age. Because they have more problems fighting acute infections, older adults are more at risk from dying of an acute condition. For example, the rate of respira- tory infection is about the same for younger and older adults, but people over age 65 account for nearly all deaths from pneumonia and influenza. For these rea- sons, health professionals strongly recommend that older adults be vaccinated against pneumonia and influenza.
Until the 1990s, chronic disease was simply viewed as a part of aging. With the publication in 1991 of the historic document Healthy People 2000: National Health Promotion and Disease Prevention (U.S. Department of Health and Human Services, 1991), the view shifted dramatically to one of prevention and wellness. As we see a bit later in this chapter, advances in understand- ing the causes of chronic disease have resulted in better
prevention in many cases, and better disease manage- ment in others.
The Role of Stress You know what it feels like to be stressed. Whether it’s from the upcoming exam in this course, the traffic jam you sat in on your way home yesterday, or the demands your children place on you, stress seems to be everywhere.
There is plenty of scientific evidence that over the long term, stress is very bad for your health. But despite thousands of scientific studies, scientists still cannot agree on a formal definition of stress. What is certain is that stress involves both physiological and psycho- logical aspects (Gouin, Glaser, Malarkey, Beversdorf, & Kiecolt-Glaser, 2012).
The most widely applied approaches to stress involve (a) focusing on the physiological responses the body makes through the nervous and endocrine sys- tems; and (b) the idea that stress is what people define as stressful. Let’s consider each in more detail.
Stress as a Physiological State. There is wide- spread agreement across many research studies that people differ in their physiological responses to stress (Campbell & Ehlert, 2012). Prolonged exposure to stress results in damaging influences from the sympa- thetic nervous system (which controls such things as heart rate, respiration, perspiration, blood flow, mus- cle strength, and mental activity) and a weakening of the immune system (Cohen, Janicki-Deverts, Doyle, Miller, Frank, Rabin et al., 2012). These effects have a direct causative effect on susceptibility to a wide range of diseases, from the common cold to cardiovascular disease, to cancer, and may play a role in shortening telomeres (see Chapter 3 ; O’Donovan et al., 2012).
Gender differences in stress responses have also been documented. There is some evidence that the hormone oxytocin plays a different role in women than in men. Oxytocin is the hormone important in repro- ductive activities, such as breast feeding, and for estab- lishing strong bonds with one’s children (Campbell, 2008). Researchers speculate that when stressed, men opt for a “flight or fight” approach whereas women opt for a “tend and befriend” approach (Taylor, 2006). Fisher-Shofty, Levkovitz, and Shamay-Tsoory (in press) showed that oxytocin improves accurate per- ception of social interactions, but in different ways in men and women. In men, performance improved
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104 CHAPTER 4
only for competition recognition, whereas in women it improved for kinship recognition.
The Stress and Coping Paradigm. Suppose you are stuck in a traffic jam. Depending on whether you are late for an important appointment or have plenty of time on your hands, you will probably feel very different about your situation. The stress and coping paradigm views stress not as an environmental stimulus or as a response but as the interaction of a thinking person and an event (Lazarus, 1984; Lazarus et al., 1985; Lazarus & Folkman, 1984). How we interpret an event such as being stuck in traffic is what matters, not the event itself or what we do in response to it. Put more formally, stress is “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Lazarus & Folkman, 1984, p. 19). Note that this definition states that stress is a transac- tional process between a person and the environment, that it takes into account personal resources, that the person’s appraisal of the situation is key, and that unless the situation is considered to be threatening, challeng- ing, or harmful, stress does not result. A diagram of the transactional model is shown in Figure 4.4 .
Appraisal. Lazarus and Folkman (1984) describe three types of appraisals of stress. Primary appraisal categorizes events into three groups based on the signifi- cance they have for our well-being: irrelevant, benign or positive, and stressful. Primary appraisals filter the events we experience. Specifically, any event that is appraised as either irrelevant (things that do not affect us) or as benign or positive (things that are good or at least neutral) is not stressful. So, we literally decide which events are potentially stressful and which ones are not. This is an important point for two reasons. First, it means we can effectively sort out the events that may be problems and those that are not, allow- ing us to concentrate on dealing with life’s difficulties more effectively. Second, it means that we could be wrong about our reading of an event. A situation that may appear at first blush to be irrelevant, for example, may actually be very important, or a situation deemed stressful initially may turn out not to be. Such mistakes in primary appraisal could set the stage for real (or imagined) crises later on.
If a person believes that an event is stressful, a second set of decisions, called secondary appraisal, is made. Secondary appraisal evaluates our per- ceived ability to cope with harm, threat, or challenge. Secondary appraisal is the equivalent of asking three questions: “What can I do?” “How likely is it that I can use one of my options successfully?” and “Will this option reduce my stress?” How we answer these ques- tions sets the stage for addressing them effectively. For example, if you believe there is something you can do in a situation that will make a difference, then your perceived stress may be reduced, and you may be able to deal with the event successfully. In contrast, if you believe there is little that you can do to address the situ- ation successfully or reduce your feelings of stress, then you may feel powerless and ineffective, even if others around you believe there are steps you could take.
Sometimes, you learn additional information or experience another situation that indicates you should reappraise the original event. Reappraisal involves making a new primary or secondary appraisal result- ing from changes in the situation. For example, you may initially dismiss an accusation that your part- ner is cheating on you (i.e., make a primary appraisal that the event is irrelevant), but after being shown pictures of your partner in a romantic situation with
Figure 4.4 An example of a transactional model of stress. Source: From Measuring Stress: A Guide For Health And Social Scientists , edited by Sheldon Cohen, Kessler & Gordon. Copyright © 1995 by Oxford University Press, Inc. Used with permission from Oxford University Press, Inc.
Stressors (environmental demands)
Benign or positive appraisal
Perceived stress
Negative emotional responses
Positive emotional responses
Appraisal of demands and adaptive capacities
Physiological or behavioral responses
Increased risk of physical and psychiatric disease
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LONGEVITY, HEALTH, AND FUNCTIONING 105
another person, you reappraise the event as stressful. Reappraisal can either increase stress (if your partner had initially denied the encounter) or lower stress (if you discovered that the photographs were fakes).
The three types of appraisals demonstrate that deter- mining whether an event is stressful is a dynamic pro- cess. Initial decisions about events may be upheld over time, or they may change in light of new information or personal experience. Different events may be appraised in the same way, and the same event may be appraised differently at any two points in time. This dynamic pro- cess helps explain why people react the way they do over the life span. For example, as our physiological abilities change with increasing age, we may have fewer physical resources to handle particular events. As a result, events that were appraised as not stressful in young adulthood may be appraised as stressful in late life.
Coping. During the secondary appraisal of an event labeled stressful in primary appraisal, we may believe there is something we can do to deal with the event effectively. Collectively, these attempts to deal with stressful events are called coping. Lazarus and Folkman (1984) view coping more formally as a complex, evolv- ing process of dealing with stress that is learned. Much like appraisals, coping is seen as a dynamic, evolving process that is fine-tuned over time. Our first attempt might fail, but if we try again in a slightly different way we may succeed. Coping is learned, not automatic. That is why we often do not cope very well with stress- ful situations we are facing for the first time (such as the end of our first love relationship). The saying “practice makes perfect” applies to coping, too. Also, coping takes time and effort. Finally, coping entails only managing the situation; we need not overcome or control it. Indeed, many stressful events cannot be fixed or undone; many times the best we can do is to learn to live with the situation. It is in this sense that we may cope with the death of a spouse.
People cope in different ways. At a general level we can distinguish between problem-focused cop- ing and emotion-focused coping. Problem-focused coping involves attempts to tackle the problem head- on. Taking medication to treat a disease and spending more time studying for an examination are examples of problem-focused coping with the stress of illness or failing a prior test. In general, problem-focused coping entails doing something directly about the problem at
hand. Emotion-focused coping involves dealing with one’s feelings about the stressful event. Allowing one- self to express anger or frustration over becoming ill or failing an exam is an example of this approach. The goal here is not necessarily to eliminate the problem, although this may happen. Rather, the purpose may be to help oneself deal with situations that are difficult or impossible to tackle head-on.
Several other behaviors can also be viewed in the context of coping. Many people use their relationship with God as the basis for their coping (Bade, 2012; Kinney, Ishler, Pargament, & Cavanaugh, 2003). For believers, using religious coping strategies usually results in positives outcomes when faced with negative events.
How well we cope depends on several factors. For example, healthy, energetic people are better able to cope with an infection than frail, sick people. Psychologically, a positive attitude about oneself and one’s abilities is also important. Good problem-solv- ing skills put one at an advantage by creating several options with which to manage the stress. Social skills and social support are important in helping one solicit suggestions and assistance from others. Finally, finan- cial resources are important; having the money to pay a mechanic to fix your car allows you to avoid the frus- tration of trying to do it yourself.
The number of stressful events, per se, is less important than one’s appraisal of them and whether the person has effective coping skills to deal with them. Of course, should the number of stressful issues exceed one’s ability to cope, then the number of issues being confronted would be a key issue.
Aging and the Stress and Coping Paradigm. Two important age-related differences in the stress and
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106 CHAPTER 4
coping paradigm are the sources of stress and the choice of coping strategies. In terms of stress, three national surveys in the United States (1983, 2006, and 2009) showed that younger adults, and those with lower lev- els of education and income reported higher stress than older adults and those with higher levels of education and income (Cohen & Janicki-Deverts, 2012).
Age differences in coping strategies across the life span are consistent (Martin et al., 2008; Meléndez,
Mayordomo, Sancho, and Tomás, 2012). One key dif- ference is that older adults are less likely to use active coping strategies and are more likely to use past experi- ence, emotion-focused, and religious coping strategies.
We explore the relation between age and stress in more detail in the How Do We Know? feature. Cairney and Krause (2008) use data from a large Canadian study to show that the experience of negative life events matters in the lives of older adults.
HOW DO WE KNOW?: NEGATIVE LIFE EVENTS AND MASTERY Who were the investigators, and what was the aim of the study? How older adults cope with the effects of stressful events related to personal mastery (whether people feel in control of things in their life) is important in understanding how people manage their lives. John Cairney and Neal Krause (2008) decided to see if expo- sure to life events affects age-related decline in feelings of mastery.
How did the investigators measure the topic of interest? To get a broad assessment of the key vari- ables, Cairney and Krause used several self-report measures. Mastery was measured by a seven-item self- report questionnaire that is widely used in this type of research (a sample item is “You have little control over the things that happen to you.”). Recent life events were measured by the number of negative life events that the respondent or someone close to the respon- dent had experienced in the previous 12 months. Physi- cian contact was measured by asking the respondent how many times he or she had seen or talked with a family physician or general practitioner in the past 12 months. Physical health concerns were measured by asking respondents about 21 chronic health conditions, and by asking about limitations in daily activities. Social support was measured by asking whether respondents had someone (a) to confide in, (b) to count on, (c) who could give them advice, and (d) who made them feel loved. Socioeconomic measures included the highest education level the respondent had obtained and a five-level measure of income adequacy.
Who were the participants in the study? The sam- ple was drawn from the longitudinal biennial National Population Health Survey (NPHS) conducted by Statis- tics Canada. This telephone survey consists of a national probability sample of Canadian residents across all 10 provinces every 2 years beginning in 1994 (Wave 1 ). For Wave 1 , of the 18,342 possible respondents aged 12 and over, 17,626 participated ( 96.1 %); 16,291 were over
age 18 . After eliminating cases with missing data, the final sample consisted of 15,410 respondents. Wave 4 (in 2000) included the same set of measures as Wave 1 for mastery, allowing a comparison over time. Of the respondents who completed Wave 1,840 died and 5,049 could not be relocated, declined to participate, or provided incomplete data in Wave 4 . This left 9,521 respondents for this longitudinal study.
What was the design of the study? Cairney and Krause used a longitudinal design with two times of measurement: 1994 and 2000.
Were there ethical concerns in the study? Because people had the right not to participate, and data were not identifiable by individual and only reported in aggre- gate, there were no ethical concerns with the study.
What were the results? Because of the problems inherent in longitudinal designs (see Chapter 1 ), Cair- ney and Krause checked for systematic differences in participants in the Wave 1 and Wave 4 data. They found that men, those from higher income groups, those with only a high school education, older adults, and those with more physical disabilities or health problems were more likely to have died by Wave 4 . Single individuals, those with lower income adequacy, with more physical disability, and with higher levels of social support were more likely to drop out by Wave 4 .
An analysis of the effects of stress on perceived mastery was done by comparing outcomes at ages 25 , 45 , and 65 . This analysis showed that at each time of measurement for people in all three age groups, exposure to more negative life events was associ- ated with decline in mastery, with this outcome being strongest with the age 65 group. Looking at the data longitudinally, the effects of more negative life events over time was greatest for the group that was age 65 in Wave 1 .
What did the investigators conclude? These find- ings show that experiencing negative life events is a major source of age-related declines in feelings of per- sonal mastery. In turn, loss of personal mastery may explain why older adults are more vulnerable to the negative effects of stress.
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LONGEVITY, HEALTH, AND FUNCTIONING 107
Effects of Stress on Health. How does stress affect us? If the stress is short, such as being stuck in a traffic jam for an hour when we’re already late in an otherwise relaxed day, the answer is that it probably will have little effect other than on our temper. But if the stress is continuous, or chronic, then the picture changes dramatically.
Chronic stress has many serious effects (Ogden, 2012), including pervasive negative effects on the immune system that cause increased susceptibility to viral infec- tions, increased risk of atherosclerosis and hypertension, and impaired memory and cognition (Webster-Marketon & Glaser, 2008). Effects can last for decades; severe stress experienced in childhood has effects that last well into adulthood (Shonkoff, Garner et al., 2012).
Research indicates that different types of apprais- als that are interpreted as stressful create different physiological outcomes (Webster-Marketon & Glaser, 2008). This may mean that how the body reacts to stress depends on the appraisal process; the reaction to different types of stress is not the same. In turn, this implies that changing people’s appraisal may also be a way to lower the impact of stress on the body.
4.3 Common Chronic Conditions and Their Management LEARNING OBJECTIVES
What are the most important issues in chronic disease?
What are some common chronic conditions across adulthood?
How can people manage chronic conditions?
Moses is a 75 -year-old African American man who worked as a lawyer all his life. Recently, he was diag- nosed as having prostate cancer. Moses has heard about several treatment options, such as surgery and radiation therapy, and he is concerned about potential side effects, such as impotence. Moses wonders what he should do.
Every day, millions of older adults get up in the morning and face another day of dealing with chronic diseases such as diabetes and arthritis. Although medi- cal advances are made every year, true cures for these conditions probably are not imminent. We considered some chronic diseases in Chapter 3 in the context of discussing age-related changes in major body systems; arthritis and cardiovascular disease were among them. In this section, we will consider other chronic condi- tions, such as diabetes and cancer. We will see that Moses’s concern about how to deal with his prostate cancer is one facing many men. As Moses will discover, in many situations there is no clear-cut “right” way to proceed. We will also examine some ways to help allevi- ate the effects of some chronic conditions and consider some ways in which we may be able to prevent such diseases or at least reduce our chances of getting them.
General Issues in Chronic Conditions Having a chronic disease does not mean that one immediately becomes incapacitated. Even though the type and severity of chronic conditions vary across people, most older adults manage to accomplish the necessary tasks of daily living despite having a chronic condition.
Chronic conditions can make life unpleasant and in some cases can increase susceptibility to other dis- eases. Understanding chronic conditions requires understanding how the four developmental forces interact. We saw in Chapter 3 that researchers are beginning to understand genetic connections with chronic conditions such as cardiovascular disease and cancer. Other biological aspects include the changes in physical systems with age, including the immune system, which can set the stage for chronic conditions. Key psychological aspects of chronic disease include the coping skills people bring to bear on their condi- tions; we consider some of these later in this chap- ter. Sociocultural factors include the lack of adequate health care, which creates barriers to treatment. The ethnic group differences in some chronic conditions, such as hypertension, are also important to keep in mind. Finally, life-cycle factors help us understand why reactions to the same chronic condition vary with the age of onset. Moreover, some conditions, such as rheumatoid arthritis, can occur at any point in adult- hood, whereas others, such as prostate cancer, tend
Adult Development in Action Design an education program for adults regarding health and the immune system, with special focus on stress and coping.
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108 CHAPTER 4
to occur mostly after midlife. As the number of older adults increases rapidly, so will the extent of chronic conditions as health problems. This will necessitate a fundamental change in health care, reflecting a shift from an acute care focus to one that focuses much more on managing chronic conditions.
Common Chronic Conditions Nearly half of adults in the United States have a chronic health condition (Centers for Disease Control and Pre- vention, 2012f ). Some of the most common, such as cardiovascular disease and arthritis, were considered in Chapter 3 . We will consider three other common conditions, diabetes mellitus, cancer, and inconti- nence, in this section.
Diabetes Mellitus. The disease diabetes mellitus occurs when the pancreas produces insufficient insulin. The primary characteristic of diabetes mellitus is above-normal sugar (glucose) in the blood and urine caused by problems in metabolizing carbohydrates. People with diabetes mellitus can go into a coma if the level of sugar gets too high, and they may lapse into unconsciousness if it gets too low.
There are two general types of diabetes (American Diabetes Association, 2012). Type I diabetes usually develops earlier in life and requires the use of insulin, hence it is sometimes called insulin-dependent diabetes. Type II diabetes typically develops in adulthood and is often effectively managed through diet. There are three groups of older adults with diabetes: those who devel- oped diabetes as children, adolescents, or young adults; those who developed diabetes in late middle age and also typically developed cardiovascular problems; and those who develop diabetes in late life and usually show mild problems. This last group includes the majority of older adults with diabetes mellitus. In adults, diabetes mellitus is often associated with obesity. The symptoms of diabetes seen in younger people (excessive thirst, increased appetite and urination, fatigue, weakness, weight loss, and impaired wound healing) may be far less prominent or absent in older adults. As a result, diabetes mellitus in older adults often is diagnosed during other medical procedures, such as eye examina- tions or hospitalizations for other conditions.
Overall, diabetes is more common among older adults and members of minority groups (Centers for Disease Control and Prevention, 2011b). The chronic effects of increased glucose levels may result in serious
complications. The most common long-term effects include nerve damage, diabetic retinopathy (discussed in Chapter 3 ), kidney disorders, cerebrovascular acci- dents (CVAs), cognitive dysfunction, damage to the coronary arteries, skin problems, and poor circula- tion in the arms and legs, which may lead to gangrene. Diabetes also increases the chance of having a stroke or developing atherosclerosis and coronary heart disease.
Although it cannot be cured, diabetes can be man- aged effectively through a low-carbohydrate and low- calorie diet; exercise; proper care of skin, gums, teeth, and feet; and medication (insulin). For older adults, it is important to address potential memory difficul- ties with the daily testing and management regimens. Education about diabetes mellitus is included in Medicare coverage, making it easier for older adults to learn how to manage the condition.
Cancer. Cancer is the second leading cause of death in the United States, behind cardiovascular disease (Centers for Disease Control and Prevention, 2012g). Over the life span, nearly one in two American men and one in three American women will develop cancer (American Cancer Society, 2012b). The risk of getting cancer increases markedly with age. About one in four men and one in five women will die from cancer. The good news is that the death rates for most types of cancer have been falling since the 1990s.
Many current deaths caused by cancer are prevent- able. Some forms of cancer, such as lung and colorectal cancer, are caused in large part by unhealthy lifestyles. Smoking causes more preventable health conditions than any other lifestyle issue. Most skin cancers can be prevented by limiting exposure to the sun’s ultraviolet rays. Clearly, changes in lifestyle would have a major impact on cancer rates.
The incidence and mortality rates of some com- mon forms of cancer in men and women are shown in Figure 4.5 . Notice that prostate cancer is the most common form of cancer in men, and breast cancer is the most common form in women (American Cancer Society, 2012b).
Death rates from various forms of cancer differ: Lung cancer kills more than three times as many men as prostate cancer and considerably more women than breast cancer (in women). Five-year survival rates for these cancers also differ dramatically. Whereas only 15 % of patients with lung cancer are still living 5 years after diagnosis, nearly 90 % of female patients with
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LONGEVITY, HEALTH, AND FUNCTIONING 109
breast cancer and over 95 % of men with prostate can- cer are (American Cancer Society, 2012b).
Why older people have a much higher incidence of cancer is not understood fully. Part of the reason is the cumulative effect of poor health habits over a long period of time, such as cigarette smoking and poor diet. In addition, the cumulative effects of exposure to pollutants and cancer-causing chemicals are partly to blame. As noted earlier in this chapter, some research- ers believe that normative age-related changes in the immune system, resulting in a decreased ability to inhibit the growth of tumors, may also be responsible.
Research in molecular biology and microbiology is increasingly pointing to genetic links, likely in combina- tion with environmental factors (Battista, Blancquaert, Laberge, van Schendel, & Leduc, 2012). The National Cancer Institute initiated the Cancer Genome Anatomy Program and an online journal and database has begun, called the Atlas of Genetics and Cytogenetics in Oncology and Haematology, in order to provide a com- prehensive list of all genes responsible for cancer.
For example, two breast cancer susceptibility genes that have been identified are BRCA1 on chro- mosome 17 and BRCA2 on chromosome 13 . When a woman carries a mutation in either BRCA1 or BRCA2, she is at a greater risk of being diagnosed with breast or ovarian cancer at some point in her life. Similarly, a potential susceptibility locus for prostate cancer has been identified on chromosome 1 , called HPC1 , which
may account for about 1 in 500 cases of prostate cancer. An additional rare mutation of HOXB13 , on chromo- some 17 , has also been identified.
Although genetic screening tests for breast and prostate cancer for the general population are not yet warranted, such tests may one day be routine. Genetics is also providing much of the exciting new research on possible treatments by giving investigators new ways to fight the disease. Age-related tissue changes have been associated with the development of tumors, some of which become cancerous; some of these may be geneti- cally linked as well. The discovery that the presence of telomerase causes cells to grow rapidly and without lim- its on the number of divisions they can undergo provides additional insights into how cancer develops (Londoño- Vallejo, 2008; see Chapter 3 ). What remains to be seen is how these genetic events interact with environmental factors, such as viruses or pollutants. Understanding this interaction process, predicted by the basic developmen- tal forces, could explain why there are great differences among individuals in when and how cancer develops.
The most effective way to address the problem of cancer is through increased use of screening tech- niques and preventive lifestyle changes. The American Cancer Society (2012c) strongly recommends these steps for people of all ages, but older adults need to be especially aware of what to do. Table 4.1 shows guide- lines for the early detection of some common forms of cancer.
*Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder. ©2013, American Cancer Society, Inc., Surveillance Research
Male Prostate
238,590 (28%) Lung & bronchus
118,080 (14%) Colon & rectum
73,680 (9%) Urinary bladder
54,610 (6%) Melanoma of the skin
45,060 (5%) Kidney & renal pelvis
40,430 (5%) Non-Hodgkin lymphoma
37,600 (4%) Oral cavity & pharynx
29,620 (3%) Leukemia
27,880 (3%) Pancreas
22,740 (3%) All sites
854,790 (100%)
Female Breast
232,340 (29%) Lung & bronchus
110,110 (14%) Colon & rectum
69,140 (9%) Uterine corpus 49,560 (6%)
Thyroid 45,310 (6%)
Non-Hodgkin lymphoma 32,140 (4%)
Melanoma of the skin 31,630 (4%)
Kidney & renal pelvis 24,720 (3%)
Pancreas 22,480 (3%)
Ovary 22,240 (3%)
All sites 805,500 (100%)
Estimated New Cases*
Male Lung & bronchus
87,260 (28%) Prostate
29,720 (10%) Colon & rectum
26,300 (9%) Pancreas
19,480 (6%) Liver & intrahepatic bile duct
14,890 (5%) Leukemia
13,660 (4%) Esophagus 12,220 (4%)
Urinary bladder 10,820 (4%)
Non-Hodgkin lymphoma 10,590 (3%)
Kidney & renal pelvis 8,780 (3%)
All sites 306,920 (100%)
Female Lung & bronchus
72,220 (26%) Breast
39,620 (14%) Colon & rectum
24,530 (9%) Pancreas
18,980 (7%) Ovary
14,030 (5%) Leukemia
10,060 (4%) Non-Hodgkin lymphoma
8,430 (3%) Uterine corpus
8,190 (3%) Liver & intrahepatic bile duct
6,780 (2%) Brain & other nervous system
6,150 (2%) All sites
273,430 (100%)
Estimated Deaths Figure 4.5 Leading new cancer cases and deaths—2012 estimates.
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110 CHAPTER 4
Table 4.1
American Cancer Society guidelines for the early detection of cancer THE AMERICAN CANCER SOCIETY RECOMMENDS THESE SCREENING GUIDELINES FOR MOST ADULTS
Breast cancer Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health
Clinical breast exam (CBE) about every 3 years for women in their 20 s and 30 s and every year for women 40 and over
Women should know how their breasts normally look and feel and report any breast change promptly to their health care provider. Breast self-exam (BSE) is an option for women starting in their 20 s.
Colorectal cancer and polyps
Beginning at age 50 , both men and women should follow one of these testing schedules:
Tests that find polyps and cancer Flexible sigmoidoscopy every 5 years, or Colonoscopy every 10 years, or Double-contrast barium enema every 5 years, or CT colonography (virtual colonoscopy) every 5 years
Tests that primarily find cancer Yearly fecal occult blood test (gFOBT), or Yearly fecal immunochemical test (FIT) every year, or Stool DNA test (sDNA)
Cervical cancer Cervical cancer screening (testing) should begin at age 21 . Women under age 21 should not be tested.
Women between ages 21 and 29 should have a Pap test every 3 years. Now there is also a test called the HPV test. HPV testing should not be used in this age group unless it is needed after an abnormal Pap test result.
Women between the ages of 30 and 65 should have a Pap test plus an HPV test (called “co-testing”) every 5 years. This is the preferred approach, but it is also OK to have a Pap test alone every 3 years.
Women over age 65 who have had regular cervical cancer testing with normal results should not be tested for cervical cancer. Once testing is stopped, it should not be started again. Women with a history of a serious cervical pre-cancer should continue to be tested for at least 20 years after that diagnosis, even if testing continues past age 65 .
A woman who has had her uterus removed (and also her cervix) for reasons not related to cervical cancer and who has no history of cervical cancer or serious pre-cancer should not be tested.
A woman who has been vaccinated against HPV should still follow the screening recommendations for her age group.
Lung cancer The American Cancer Society does not recommend tests to screen for lung cancer in people who are at average risk of this disease. However, the ACS does have screening guidelines for individuals who are at high risk of lung cancer due to cigarette smoking.
Prostate cancer The American Cancer Society recommends that men make an informed decision with their doctor about whether to be tested for prostate cancer. Research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment. The American Cancer Society believes that men should not be tested without learning about what we know and don’t know about the risks and possible benefits of testing and treatment.
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LONGEVITY, HEALTH, AND FUNCTIONING 111
As Moses is learning, one of the biggest con- troversies in cancer prevention concerns screen- ing and treatment for prostate cancer. The Current Controversies feature summarizes the issues: lack of data about the causes and the course of the disease and disagreement over treatment approaches. This con- troversy mirrors similar debates over the treatment of
breast cancer, contrasting the relative merits of regular screening mammography, and treatment approaches including radical mastectomy (removal of the breast and some surrounding tissue) versus lumpectomy (removal of the cancerous tumor only) and how che- motherapy, radiation, and drugs such as tamoxifen fit into the overall treatment approach.
Take control of your health, and reduce your cancer risk
Stay away from tobacco. Stay at a healthy weight. Get moving with regular physical activity. Eat healthy with plenty of fruits and vegetables. Limit how much alcohol you drink (if you drink at all). Protect your skin. Know yourself, your family history, and your risks. Have regular check-ups and cancer screening tests. For information on how to reduce your cancer risk and other questions about cancer,
please call us anytime, day or night, at 1-800-227-2345 or visit us online at www.cancer.org .
CURRENT CONTROVERSIES: THE PROSTATE CANCER DILEMMA Roughly the size of a walnut and weighing about an ounce, the prostate gland is an unlikely candidate to create a major medical controversy. The prostate is located in front of the rectum and below the bladder and wraps around the urethra (the tube carrying urine out through the penis). Its primary function is to pro- duce fluid for semen, the liquid that transports sperm. In half of all men over age 60 , the prostate tends to enlarge, which may produce such symptoms as diffi- culty in urinating and frequent nighttime urination.
Enlargement of the prostate can happen for three main reasons: prostatitis (an inflammation of the pros- tate that is usually caused by an infection), benign pros- tatic hyperplasia (BPH), and prostate cancer. BPH is a noncancerous enlargement of the prostate that affects the innermost part of the prostate first. This often results in urination problems as the prostate gradu- ally squeezes the urethra, but it does not affect sexual functioning.
Prostate cancer often begins on the outer por- tion of the prostate, which seldom causes symptoms in the early stages. Each year, more than 240,000 men in
the United States are diagnosed with prostate cancer; nearly 30,000 die (National Cancer Institute, 2012). For reasons we do not yet understand, African American men such as Moses have a 40 % higher chance of get- ting prostate cancer. In addition, a genetic link is clear: A man whose brother has prostate cancer is four times more likely to get prostate cancer than a man with no brothers having the disease.
Part of the controversy surrounding prostate can- cer relates to whether early detection reduces mortal- ity from the disease. Research investigating whether screening for early detection of prostate cancer saved lives indicated that, overall, it did not, and may actually create problems such as unnecessary treatment because most forms of prostate cancer are very slow growing. This lack of data led the U.S. Preventive Services Task Force, the Canadian Task Force on the Periodic Health Examination, and others to recommend abandoning routine prostate cancer screening because of the cost and the uncertain benefits associated with it.
The American Cancer Society and the National Comprehensive Cancer Network jointly created a guide to prostate cancer screening and treatment to help men negotiate the confusing state of affairs (American Can- cer Society, 2012a; National Comprehensive Cancer Net- work, 2012). The background information provided by
Source: http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer
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112 CHAPTER 4
In general, cancer treatment involves several major approaches that are typically used in combination: sur- gery, chemotherapy, radiation, and others (e.g., bio- logical therapy, gene therapy, bone marrow transplant). In addition, numerous alternative therapies, such as herbal approaches, exist. Continued advances in genetic research probably will result in genetically engi- neered medications designed to attack cancer cells. As with any health care decision, people with cancer need to become as educated as possible about the options.
Incontinence. For many people, the loss of the ability to control the elimination of urine and feces on an occasional or consistent basis, called incontinence , is a source of great concern and embarrassment. As you can imagine, incontinence can result in social isolation and lower quality of life if no steps are taken to address the problem.
Urinary incontinence, the most common form, increases with age and varies across ethnic groups as a function of gender (Shamliyan, Wyman, & Kane, 2012; Tennstedt et al., 2008). Among community-dwelling older adults, roughly 20 % of women and 10 % of men have urinary incontinence. But rates are much higher if the person has dementia and is living in the com- munity (about 35 %) or if the person is living in a nurs- ing home (roughly 70 %). European American women report a higher rate of urinary incontinence than either African American or Latina women; rates for men do not vary across ethnic groups.
Urinary incontinence occurs most often for four major reasons (Mayo Clinic, 2012d). Stress inconti- nence happens when pressure in the abdomen exceeds the ability to resist urinary flow. This may occur when a person coughs, sneezes, exercises, or lifts a heavy object. Urge incontinence usually is caused by a central nervous system problem after a stroke or urinary tract infection. People feel the urge to urinate but cannot get to a toilet quickly enough. Overflow incontinence results from improper contraction of the kidneys, caus- ing the bladder to become overdistended. Certain drugs, tumors, and prostate enlargement are common causes of overflow incontinence. Functional incontinence occurs when the urinary tract is intact but because of physical disability or cognitive impairment the person is unaware of the need to urinate. This is the most com- mon form in people with dementia, Parkinson’s dis- ease, or arthritis.
Most types of incontinence can be alleviated with interventions. Among the most effective are behavioral interventions, which include diet changes, relearning to recognize the need to toilet, and pelvic floor muscle training for stress incontinence (Shamliyan et al., 2012; Zahariou, Karamouti, & Papaioannou, 2008). Certain medications and surgical intervention may be needed in some cases. Numerous products such as protective undergarments and padding also are available to help absorb leaks. All these options help alleviate the psy- chological and social effects of incontinence and help
these organizations can help men decide what, if any, screening and treatment options are best for them.
The sharp division among medical experts high- lights the relation between carefully conducted research and public health policy. At present, there has been insufficient comparison of various treat- ment options (which include surgery, radiation, hormones, and drugs), and we do not fully under- stand the natural course of prostate cancer in terms of which types of tumors grow rapidly or spread to other organs and the typical type that grows slowly and does not. Given that some of the side effects of surgery include urinary incontinence and impotence, and that some of the other therapies may produce other unpleasant effects, there is debate on whether the disease should be treated at all in most patients (National Cancer Institute, 2012).
At present, men who experience prostate- related symptoms are left to decide for themselves, in consultation with their physician, what to do. Many men opt for immediate treatment and learn how to live with any subsequent side effects. Support groups for men with prostate cancer are becoming more common, and many encourage the patient’s partner to participate.
The controversy surrounding early screening and detection of prostate cancer is unlikely to sub- side soon because the necessary research concern- ing effective treatment and survival will take years to conduct. Until then, if you or someone you know is over 50 or is in a high-risk group, the decision still must be made. Talk at length with a physician who is up-to-date on the topic and educate yourself about the alternatives.
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LONGEVITY, HEALTH, AND FUNCTIONING 113
people live better lives (Markland, Vaughan, Johnson, Burgio, & Goode, 2012).
Managing Pain People do not like to be in pain, and they fear pain more than almost any other aspect of disease. Per- haps that is because pain is one of the most unpleasant aspects of many chronic diseases. Pain is disruptive, saps energy, negatively affects quality of life, and can lead to an ever-intensifying cycle of pain, anxiety, and anguish. Pain is also one of the most common com- plaints of older adults, affecting more than 40 % of community-dwelling elderly on a regular basis (Shega, Dale, Andrew, Paice, Rockwood, & Weiner, 2012). Pain does not necessarily reflect the same things as pain in younger adults; for older adults it is not only an indica- tion that something is wrong, but can also be respon- sible for depression, sleep disorders, decreased social interaction, impaired mobility, and increased health care costs (Karp et al., 2008).
Unfortunately, many myths exist about pain in older adults, such as that older adults should simply accept the physical pain they experience as part of growing older. Failure to understand the real nature of pain in older adults can lead to a failure to relieve it.
How do people manage pain? Perhaps the most important aspects are to understand that pain is not a necessary part of treatment, people can control their pain, no one approach is likely to be sufficient, and ask- ing for pain relief is to be expected. There are two gen- eral pain management techniques: pharmacological and nonpharmacological (WebMD, 2010). These approaches often are used together for maximum pain relief.
Pharmacological approaches to pain manage- ment include nonnarcotic and narcotic medications. Nonnarcotic medications are best for mild to moder- ate pain, while narcotic medications are best for severe pain. Nonnarcotic medications include NSAIDs (non- steroidal anti-inflammatory drugs), such as ibupro- fen and acetaminophen. However, these drugs must be used with caution because they may cause toxic side effects in older adults. Narcotic drugs that work well in older adults include morphine and codeine; other commonly used drugs, such as meperidine and pentazocine, should be avoided because of age-related changes in metabolism. Patients taking any of these medications must be monitored very closely.
Nonpharmacological pain control includes a variety of approaches, all of which are effective with some people; the trick is to keep trying until the best approach is found. Common techniques include the following:
Deep and superficial stimulation of the skin through therapeutic touch, massage, vibration, heat, cold, and various ointments
Electrical stimulation over the pain site or to the spine
Acupuncture and acupressure Biofeedback, in which a person learns to control
and change the body processes responsible for the pain
Distraction techniques such as soft music that draw a person’s attention away from the pain
Relaxation, meditation, and imagery approaches that rid the mind of tension and anxiety
Hypnosis, either self-induced or induced by another person
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The most important point is that pain is not a nec- essary part of growing old or having a disease. Pain relief is an important part of recovery and should be included in any treatment regimen for adults of all ages.
4.4 Pharmacology and Medication Adherence LEARNING OBJECTIVES
What are the developmental trends in using medication?
How does aging affect the way the medications work?
What are the consequences of medication interactions?
What are the important medication adherence issues?
Lucy is an 80 -year-old woman who has several chronic health problems. As a result, she takes 12 medications every day. She must follow the regimen very carefully; some of her medications must be taken with food, some on an empty stomach, and some at bedtime. Lucy’s daughter is concerned that Lucy may experience serious problems if she fails to take her medications properly.
One of the most important health issues for older adults is the use of both prescription and over-the- counter medications. In fact, older adults take more medications on average than any other age group, roughly half of all drugs prescribed in the United States. When over-the-counter drugs are included, this translates into about six or seven medications per older adult; Lucy takes more than the average. Like Lucy, most people take these drugs to relieve pain or related problems resulting from chronic conditions.
Patterns of Medication Use The explosion of new prescription and over-the- counter medications over the past few decades has
created many options for physicians in treating disease, especially chronic conditions. Although advances in medication are highly desirable, there are hidden dangers for older adults (U.S. Food and Drug Administration, 2012).
Until the late 1990s, clinical trials of new medica- tions were not required to include older adults. Thus, for most of the medications currently on the market, we do not know whether they are as effective for older adults as they are for younger or middle-aged adults. Equally important, because of normative changes in metabolism with age, the effective dosage of medica- tions may change as people get older, which can mean a greater risk of overdose with potentially serious con- sequences, including death, or the need to increase the dose in order to get the desired effect.
When one considers that many of these newer, often more effective medications are very expensive, the ability of many older adults to afford the best med- ication treatments is questionable. The prescription drug insurance most older Americans have through Medicare still leaves significant deductibles and co- payments that are too high for many low income older adults. Additionally, figuring out which option is best can be quite complex, serving as a further barrier. (You can get much more information from the official Medicare prescription drug coverage website.)
As even more medications are developed and approved, the use of multiple medications will con- tinue and likely increase. When used appropriately, medications can improve people’s lives; when used inappropriately, they can cause harm. Understanding how medications work and how these processes change with age is extremely important.
Developmental Changes in How Medications Work
When Lucy takes her medications every day, what hap- pens? Understanding how medications work involves knowing the developmental changes in absorption, distribution, metabolism, and excretion of medica- tions (Hacker, Messer, & Bachmann, 2009).
Absorption is the time needed for one of Lucy’s medi- cations to enter the bloodstream. For drugs taken orally, a key factor is the time it takes for the medication to go from the stomach to the small intestine, where maxi- mum absorption occurs. This transfer may take longer
Adult Development in Actions Given the higher frequency of chronic disease with age, what issues would you, as a professional human resources expert, need to include in creating support programs for employees?
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LONGEVITY, HEALTH, AND FUNCTIONING 115
than expected in older adults, resulting in too little or too much absorption, depending on the drug. For example, if a drug takes longer to transfer from the stomach to the small intestine in older adults, too little of the drug may be left to be effective. However, once in the small intes- tine, absorption does not appear to differ among older, middle-aged, or younger adults (Hacker et al., 2009).
Once in the bloodstream, the medication is dis- tributed throughout the body. How well distribution occurs depends on the adequacy of the cardiovascular system. Maximal effectiveness of a drug depends on the balance between the portions of the drug that bind with plasma protein and the portions that remain free. As we grow older, more portions of the drug remain free; this means that toxic levels of a drug can build up more easily in older adults.
Similarly, drugs that are soluble in water or fat tissue can also build up more easily in older adults because of age-related decreases in total body water or possible increases in fat tissue. The effective dosage of a drug depends critically on the amount of free drug in the body; thus, whether the person is young or old, thin or obese, is very important to keep in mind (Lilley, Rainforth Collins, & Snyder, in press).
Getting rid of medications in the bloodstream is partly the job of the liver, a process called drug metabo- lism . There is much evidence that this process is slower in older adults, meaning that drugs stay in the body longer as people grow older (Le Couteur, McLachan, & de Cabo, 2012). Slower drug metabolism can also cre- ate the potential for toxicity if the medication schedule does not take this into account.
Sometimes drugs are decomposed into other com- pounds to help eliminate them. Drug excretion occurs mainly through the kidneys in urine, although some elimination occurs through feces, sweat, and saliva. Changes in kidney function with age, related to lower total body water content, are common. This means that drugs often are not excreted as quickly by older adults, again setting the stage for possible toxic effects (Le Couteur et al., 2012).
What do these changes mean? Most important, the dosage of a drug needed to get the desired effect may be different for older adults than for middle-aged or younger adults. In many cases, physicians recom- mend using one-third to one-half the usual adult dos- age when the difference between the effective dosages
and toxic dosages is small or there is a high rate of side effects (Le Couteur et al., 2012). In addition, because of age-related physiological changes, several drugs are not recommended for use by older adults. In general, a dosage strategy of “start low and go slow” is best.
Medication Side Effects and Interactions Because of their high rate of medication use, older adults also have the highest risk of adverse drug effects (Le Couteur et al., 2012; Lilley et al., in press; U.S. Food and Drug Administration, 2012). In part, these problems result from physiological changes that occur with age in how drugs are absorbed into the body, how long they remain, and how well they work. For exam- ple, changes in the stomach may slow down the rate at which drugs enter the body, meaning that achiev- ing the effective level of the drug in the body may take longer. Changes in liver and kidney functioning affect how rapidly the drug is removed and excreted from the body, meaning that levels of the drug may remain high for longer periods of time.
As we have seen, age-related increases in the fre- quency of chronic conditions means that older adults are likely to have more than one medical problem for which they take medications. In this regard, Lucy is fairly typical. Treating multiple conditions results in polypharmacy, the use of multiple medications. Polypharmacy is potentially dangerous because many drugs do not interact well; the action of some drugs is enhanced in combination with others, whereas other drugs may not work at all in combination. Drug inter- actions may create secondary medical problems that in turn need to be treated, and the primary condition may not be treated as effectively. Moreover, drug interac- tions can produce symptoms that appear to be caused by other diseases; in some cases they may cause confu- sion and memory loss that mimics Alzheimer’s disease. Professionals and family members need to monitor the situation closely (Arnold, 2008).
Lucy’s daughter is correct in worrying about her mother taking her medications as prescribed. Analyzing a person’s medication regimen, includ- ing both prescription and over-the-counter medica- tions, and asking the patient or caregiver to describe how they are taken is important in diagnosing health problems. Given the high level of medication use among older adults, what can be done to minimize
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116 CHAPTER 4
drug interaction effects? Physicians play a key role, but other health care professionals also must be alert because older adults typically go to more than one physician. Accurate medication histories including all types of medicines are essential. Inappropriate use of drugs, such as antipsychotics to control behavior, must also be monitored.
Adherence to Medication Regimens The likelihood of adverse drug reactions increases as the number of medications increases. Taking more drugs also means that keeping track of each becomes more difficult. Imagine having to keep track of six different medications, each of which has a different schedule, as presented in Table 4.2 .
Medication adherence (taking medications cor- rectly) becomes less likely the more drugs people take and the more complicated the regimens are. Combined with sensory, physical, and cognitive changes in older adults, medication adherence is a significant problem
in this age group (Shea, 2006). Prospective memory, remembering to take one’s medication at a future time, is critical to good adherence to a medication regimen (Zogg, Woods, Sauceda, Wiebe, & Simoni, 2012). The oldest old are especially at risk; the most common problem is that they simply forget to take the medica- tion. (We consider ways to help people remember to take their medications in Chapter 7 .) Yet adherence is crucial to treatment success. Christensen and Johnson (2002) present an interactive model that describes the context of patient adherence. This model is shown in Figure 4.6 .
The best approach, of course, is to keep the number of medications to a minimum (Shea, 2006). If the use of drugs is determined to be essential, then periodic reevaluations should be conducted and the medication discontinued when possible. In addition, the lowest effective dosage should be used. In general, medication use by older adults should get the same careful consid- eration as by any other age group.
Figure 4.6 Conceptual representation of the patient-by-treatment- context interactive framework. The dashed lines reflect the fact that research generally does not find that patient characteristics or contextual features have a significant effect on adherence. © 2015 Cengage Learning
Table 4.2
Example of a complex medication regimen Morning Dinner Bedtime
Large yellow pill Take 1 each day with food
Small blue pill Take 1 every other day
Small white pill Take 2 per day for two days, then 1 per day; repeat
Round pink tablet Take 1 every other day
Oval white pill Take 2 each night with plenty of water
Small yellow pill Take one per week
Patient characteristics (e.g., coping style, traits, expectancies, or beliefs)
Treatment context moderators (e.g., treatment controllability,
predictability, or illness severity)
Patient X treatment
context Patient adherence
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LONGEVITY, HEALTH, AND FUNCTIONING 117
daily walks and shopping and to feel optimistic about the future (Verbrugge, 1994, 2005). This is especially true for the oldest old (Fauth, Zarit, & Malmberg, 2008). Social context also matters for older adults, as disablement is associated with much higher loneliness on one hand, and positive marital relationships are associated with lower impairment (Warner & Kelley- Moore, 2012).
In the context of chronic conditions, disability is the effects of chronic conditions on people’s ability to engage in activities that are necessary, expected, and personally desired in their society (Verbrugge, 1994, 2005). When people are disabled as a result of a chronic condition, they have difficulty doing daily tasks, such as house- hold chores, personal care, job duties, active recre- ation, socializing with friends and family, and errands. One of the most important research efforts related to health and aging is seeking to understand how disabil- ity results from chronic conditions and what might be done to help prevent it. For these reasons, it is impor- tant to understand the changing context of disability in the United States.
Researchers point out that as the age at which dis- ablement occurs in late life gets closer to the end of life, these changes create what is called the compres- sion of morbidity (Andersen, Sebastiani, Dworkis, Feldman, & Perls, 2012; Lindley, 2012). Compression of morbidity refers to the situation in which the aver- age age when one becomes disabled for the first time is postponed, causing the time between the onset of disabil- ity and death to be compressed into a shorter period of time. This implies that older adults in the United States are becoming disabled later in life than previously, and are disabled a shorter time before dying than in past generations.
Verbrugge and Jette (1994) originally proposed an excellent comprehensive model of disability resulting from chronic conditions, a model that has greatly influ- enced research (see Figure 4.7 ). The model consists of four main parts. The main pathway emphasizes the relations between pathology (the chronic conditions a person has), impairments of organ systems (such as muscular degeneration), functional limitations in the ability to perform activities (such as restrictions in one’s mobility), and disability.
The model also includes risk factors and two types of intervention strategies: environmental and health
Adult Development in Action If you were a home health aide, what would you do to help your clients remember to take their medications? (Write down your answer and then see if you came up with similar ideas as you will read about in Chapter 7 .)
4.5 Functional Health and Disability LEARNING OBJECTIVES
What factors are important to include in a model of disability in late life?
What is functional health? What causes functional limitations and disability
in older adults?
Brian is a 68 -year-old former welder who retired 3 years ago. He and his wife, Dorothy, had planned to travel in their RV and see the country. But Brian’s arthritis has been getting worse lately, and he is having increasing dif- ficulty getting around and doing basic daily tasks. Brian and Dorothy wonder what the future holds for them.
Brian and Dorothy are not alone. Many couples plan to travel or to do other activities after they retire, only to find health issues complicating the situation. As the focus on health has shifted over the past several decades to chronic disease, researchers have increas- ingly focused on how well people can function in their daily lives. In this section, we examine how functional health is determined and how disability occurs.
A Model of Disability in Late Life As we saw earlier in this chapter, one defining charac- teristic of a chronic condition is that it lasts a long time. This means that for most adults, the time between the onset of a chronic condition and death is long, mea- sured in years and even decades. Chronic diseases typically involve some level of discomfort, and physi- cal limitations are common, everyday issues for most people, as they are for Brian. Over the course of the disease, these problems usually increase, resulting in more efforts by patients and health care workers to try to slow the progress of the disease. In many cases, these efforts allow people to resume such activities as
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118 CHAPTER 4
care ( extraindividual factors ) and behavioral and per- sonality ( intraindividual factors ). Risk factors are long-standing behaviors or conditions that increase one’s chances of functional limitation or disability. Examples of risk factors include low socioeconomic status, chronic health conditions, and health-related behav- iors such as smoking. Extraindividual factors include
interventions such as surgery, medication, social sup- port services (e.g., Meals on Wheels), and physical environmental supports (e.g., wheelchair ramps). The presence of these factors often helps people maintain their independence and may make the difference between living at home and living in a long-term care facility. Intraindividual factors include such things as
Figure 4.7 A model of the disablement process. Source: Verbrugge, L.M., & Jette, A.M. (1994). The disablement process. Social Science and Medicine, 38, 4. Reprinted with permission.
Extraindividual Factors
Medical care and rehabilitation (surgery, physical therapy, speech therapy, counseling, health education, job retraining, etc.)
Medications and other therapeutic regimens (drugs, recreational therapy, aquatic exercise, biofeedback, meditation, rest, energy conservation, etc.)
External supports (personal assistance, special equipment and devices, standby assistance and supervision, day care, respite care, Meals on Wheels, etc.)
Built, physical, and social environment (structural modifications at job and home, access to buildings and public transportation, improvement of air quality, reduction of noise and glare, health insurance and access to medical care, laws and regulations, employment discrimination, etc.)
Intraindividual Factors
Lifestyle and behavior changes (overt changes to alter disease activity and impact)
Psychological attributes and coping (positive affect, emotional vigor, prayer, locus of control, cognitive adaptation to one’s situation, confident, peer support groups, etc.)
Activity accommodations (changes in kinds of activities, procedures for doing them, frequency or length of time doing them)
The Main Pathway
Pathology (diagnoses of disease, injury, congenital or developmental condition)
Risk Factors (predisposing characteristics: demographic, social, lifestyle, behavioral, psychological, environmental, biological)
Impairments (dysfunctions and structural abnormalities in specific body systems: musculoskeletal, cardiovascular, neurological, etc.)
Functional limitations (restrictions in basic physical and mental actions: ambulate, reach, stoop, climb stairs, produce intelligible speech, see standard print, etc.)
Disability (difficulty doing activities of daily life: job, household management, personal care, hobbies, active recreation, clubs, socializing with friends and kin, child care, errands, sleep, trips, etc.)
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LONGEVITY, HEALTH, AND FUNCTIONING 119
beginning an exercise program, keeping a positive out- look, and taking advantage of transportation programs to increase mobility.
Extraindividual and intraindividual interven- tions are both aimed at reducing the restrictions and difficulties resulting from chronic conditions. Unfortunately, sometimes they do not work as intended and may even create problems of their own. For example, a prescribed medication may produce negative side effects that, instead of alleviating the condition, create a new problem. Or social service agencies may have inflexible policies about when a particular program is available, which may make it difficult for a person who needs the program to participate. Such situations are called exacerbators , because they make the situation worse than it was originally. Although they may be unintended, the results of exacerbators can be serious and necessitate additional forms of intervention.
One of the most important aspects of Verbrugge and Jette’s (1994) model is the emphasis on the fit between the person and the environment, a topic we explore in detail in Chapter 5 . When a person’s needs are met by the environment, the person’s quality of life and adaptation are optimal.
Verbrugge and Jette’s model has been extended and validated in several ways. For example, the basic aspects of the model were extended to explain the dis- ablement process in osteoarthritis (Wang, Chern, & Chiou, 2005). Femia, Zarit, and Johansson (2001), and Fauth and colleagues (2008) validated the model in research on older adults over age 79 in Sweden. Among the most important results were the mediating role of psychosocial factors such as mastery, depression, and loneliness on risk factors for disability; for example, higher feelings of mastery resulted in lower levels of disability. And the model is helping in the develop- ment of a new approach to classifying disability in China (Purser, Feng, Yi, & Hoenig, 2012).
Determining Functional Health Status How can we determine where a person can be cat- egorized along Verbrugge and Jette’s continuum? The answer to this question describes a person’s functional health status , that is, how well the person is func- tioning in daily life. Determining functional health status requires very careful assessment in order to
differentiate the tasks a person reports he or she can do, tasks a person can demonstrate in a laboratory or clinic that simulate the same tasks at home, and tasks the person actually does at home (Kingston, Collerton, Davies, Bond, Robinson, & Jagger, 2012).
Most of the time, assessing functional health sta- tus is done for a very practical reason: to identify older adults who need help with everyday tasks. Frail older adults are those who have physical disabilities, are very ill, and may have cognitive or psychological disorders and need assistance with everyday tasks. They con- stitute a minority of older adults, but the size of this group increases a great deal with age.
Frail older adults are people whose competence is declining. However, they do not have one specific problem that differentiates them from their active, healthy counterparts; rather, they tend to have several (Rockwood et al., 2004). To identify the areas in which people experience limited functioning, researchers have developed observational and self-report tech- niques to measure how well people can accomplish daily tasks.
Everyday competence assessment consists of examining how well people can complete activities of daily living and instrumental activities of daily living (Gold, 2012). Activities of daily living (ADLs) include basic self-care tasks such as eating, bathing, toileting, walking, or dressing. A person can be considered frail if he or she needs help with one or more of these tasks. Instrumental activities of daily living (IADLs) are actions that entail some intellectual competence and planning. Which activities constitute IADLs varies widely across cultures. For example, for most adults in Western culture, IADLs would include shopping for personal items, paying bills, making telephone calls, taking medications appropriately, and keeping appointments. In other cultures, IADLs might include caring for animal herds, making bread, threshing grain, and tending crops.
The number of older adults who need assis- tance with ADLs and IADLs has declined somewhat since the early 1990s, as you can see in Figure 4.8 (AgingStats.gov, 2012b). About 26 % of older adults enrolled in Medicare need assistance with at least one ADL, about 12 % need help with at least one IADL, and about 4 % are sufficiently impaired that they live in an assisted living or nursing home facility.
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120 CHAPTER 4
As you can see in Figure 4.9 , the percentage of people needing assistance increases with age, from 8.2 % of people aged 65 – 69 to 30 % of those over age 80 (Administration on Aging, 2012a). The percentage of people needing assistance also varies across ethnic groups, with Asian Americans and European Americans having the lowest rate, African Americans and American Indian/Alaska Native/Native Hawaiian/Other Pacific Islander having the highest, and Latinos being in the middle (National Center for Health Statistics, 2012c).
In addition to basic assistance with ADLs and IADLs, frail older adults have other needs. Research shows that these individuals are also more prone to depression and anxiety disorders ( AgingStats.gov , 2012b). Although frailty becomes more likely with increasing age, especially during the last year of life, there are many ways to provide a supportive environ- ment for frail older adults. We take a closer look at some of them in Chapter 5 .
What Causes Functional Limitations and Disability in Older Adults?
As you were reading about the Verbrugge and Jette (1994) model, you may have been thinking about Brian’s situation and those of other adults you know. If you and your classmates created a list of all the condi- tions you believe cause functional limitations and dis- abilities in older adults, the list undoubtedly would be long. (Try it and see for yourself.) But by strategically combining a large representative sample of conditions with sophisticated statistical analyses, this list can be shortened greatly. If these steps are taken, what condi- tions best predict future problems in functioning?
In a classic longitudinal study conducted over three decades, Strawbridge and colleagues (1998) found that smoking, heavy drinking, physical inactivity, depres- sion, social isolation, and fair or poor perceived health predicted who would become disabled in some way. As
Percent
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Long-term care facility 5 to 6 ADLs 3 to 4 ADLs
1 to 2 ADLs
IADLs only
NOTE: A residence is considered a long-term care facility if it is certified by Medicare or Medicaid; has three or more beds, is licensed as a nursing home or other long-term care facility, and provides at least one personal care service; or provides 24-hour, 7-day-a-week supervision by a caregiver. ADL limitations refer to difficulty performing (or inability to perform for a health reason) one or more of the following tasks: bathing, dressing, eating, getting in/out of chairs, walking, or using the toilet. IADL limitations refer to difficulty performing (or inability to perform for a health reason) one or more of the following tasks: using the telephone, light housework, heavy housework, meal preparation, shopping, or managing money. Percents are age-adjusted using the 2000 standard population. Estimates may not sum to the totals because of rounding. Reference population: These data refer to Medicare enrollees.
Figure 4.8 Percentage of Medicare enrollees age 65 and over who have limitations in activities of daily living (ADLs) or instrumental activities of daily living (IADLs), or who are in a facility, selected years 1992–2009. Source: http://www.census.gov/ipc/www/idb/tables.html.
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LONGEVITY, HEALTH, AND FUNCTIONING 121
predicted by Verbrugge and Jette (1994), lack of physi- cal activity is a powerful predictor of later disability and with higher rates of cancer, cardiovascular disease, diabetes, and obesity, all of which result in higher rates of disability and premature death (Gretebeck, Ferraro, Black, Holland, & Gretebeck, 2012).
How Important Are Socioeconomic Factors? Once we have identified the specific conditions that are highly predictive of future functional limitations, an important question is whether the appropriate intervention and prevention programs should be tar- geted at particular groups of people. That is, would people who are well educated and have high incomes have the same rate of key chronic conditions as people in lower socioeconomic groups? If not, then people with different socioeconomic backgrounds have different needs.
Research indicates a fairly strong and consis- tent relationship between socioeconomic status and health-related quality of life. Across all racial and ethnic groups, more affluent older adults have lower levels of disability and higher health-related quality of life than individuals in lower socioeconomic groups (Administration on Aging, 2012a; National Center for Health Statistics, 2012c). A Canadian study showed that this difference appears to be set in early adulthood and maintained into late life (Ross, Garner, Bernier, Feeny, Kaplan, McFarland et al., 2012).
How Does Disability in Older Adults Differ Globally? Throughout this and previous chapters, we have encountered important differences between men and women and between various ethnic/racial and socioeconomic groups. Do these patterns hold globally?
Not surprisingly, the answer is “yes” (World Health Organization, 2012). As the number of older adults rises around the world, the number of people with dis- abilities or functional limitations does, too. Also, the rates of disabilities are higher in low-income countries and among women. Early detection and treatment of chronic disease can lower these rates.
Looked at more closely, some interesting patterns emerge. The United States, for example, has higher rates of most chronic diseases and functional impair- ment than England or the rest of Europe (National Institute on Aging, 2012a). An important difference is access to health care, in terms of whether everyone is guaranteed access by the government or not.
0
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35
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Bathing/ Showering
Dressing Eating Getting in/out of bed/chairs
Walking Using toilet
Figure 4.9 Percent of persons with limitations in activities of daily living by age group: 2009. Source: http://www.aoa.gov/AoARoot/ Aging_Statistics/Profile/2011/16.aspx
Adult Development in Action If you were a social policy leader, what national poli- cies need to be addressed to best prepare the United States for the coming rapid increase in older adults and the resulting increase in functional limitations in this population?
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122 CHAPTER 4
Summary 4.1 How Long Will We Live?
What is the average and maximum longevity for humans?
Average longevity is the age at which half of the people born in a particular year will have died. Maximum longevity is the longest time a member of a species lives. Active longevity is the time dur- ing which people are independent. Dependent life expectancy is the time during which people rely on others for daily life tasks.
Average longevity increased dramatically in the first half of the 20 th century, but maximum longev- ity remains at about 120 years. The increase in aver- age longevity resulted mainly from the elimination
of many diseases and a reduction in deaths during childbirth.
What genetic and environmental factors influence longevity?
Having long- or short-lived parents is a good pre- dictor of your own longevity.
Living in a polluted environment can dramatically shorten longevity; being in a committed relation- ship lengthens it. Environmental effects must be considered in combination with each other and with genetic influences.
What ethnic factors influence average longevity? Different ethnic groups in the United States have
different average longevity. However, these dif- ferences result primarily from differences in nutri- tion, health care, stress, and socioeconomic status.
Social Policy Implications Two demographic trends will create the potential for significant worldwide change over the next few decades. First, increasing longevity in developed coun- tries will result in many more older adults. This means that societies and governments will have increased pressure to provide services tailored to older adults. Such services are often much more expensive. For exam- ple, health care for older adults costs more because it involves treating more chronic diseases and more inten- sive intervention over time.
Second, the size of various generations will affect the scope of this change. For instance, the large baby- boom generation, combined with increased longev- ity, will make the issue of more older adults acute; the lower birth rate of the subsequent generation will lessen the pressures in future decades by lower- ing the relative proportion of the population that is over age 65 .
What does this mean? For the next few decades there will be increased emphasis on social policies and services that directly benefit older adults, and they are likely to demand them. While they have the numbers, and the concomitant political power, such policies are likely to be adopted, perhaps to the detriment of younger generations.
This changing political climate plays out in elec- tions. You may remember that in the 2012 presidential
election campaign there was great debate over chang- ing the rules by which Medicare operates (e.g., chang- ing the age of eligibility, switching from a defined benefit program to a defined contribution program, etc.). The commentary on both sides of the issue was loud, even from older adults who would not have been affected by any of the proposed changes.
As the baby boomers age and die, though, two further things will occur. First, there will be a tremen- dous transfer of wealth to a smaller generation, with the likely outcome of concentrating wealth in fewer hands. Second, policies generally favorable to older adults may get changed as the next large generation (the baby boomers’ children and grandchildren) enters middle age.
These shifts in policy could have major implications for everything from housing (e.g., more state and fed- eral support for subsidized housing for older adults) to health care (e.g., substantially more expenditures for older adults’ health care). If the policies change to reflect the demographic needs of the day, then such policies may need to be undone in the future, which is often politically difficult to accomplish. Close attention to all these issues is necessary for the best policies to be enacted.
So what do you think? What policies need to be changed? How?
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LONGEVITY, HEALTH, AND FUNCTIONING 123
In late life, people in some ethnic minority groups live longer than European Americans.
What factors create gender differences in average longevity?
Women tend to live longer than men, partly because men are more susceptible to disease and environmental influences. Numerous hypotheses have been offered for this difference, but none have been supported strongly.
4.2 Health and Illness
What are the key issues in defining health and illness?
Health is the absence of acute and chronic physi- cal or mental disease and impairments. Illness is the presence of a physical or mental disease or impairment.
Self-rated health is a good predictor of illness and mortality. However, gender and cultural differ- ences have been found.
How is the quality of life assessed? Quality of life is a multidimensional concept that
encompasses biological, psychological, and socio- cultural domains at any point in the life cycle.
In the context of health, people’s valuation of life is a major factor in quality of life.
What normative age-related changes occur in the immune system?
The immune system is composed of three major types of cells, which form a network of interacting parts: cell-mediated immunity (consisting of thy- mus-derived, or T-lymphocytes), humoral immunity (B-lymphocytes), and nonspecific immunity (mono- cytes and polymorphonuclear neutrophil leuko- cytes). Natural killer (NK) cells are also important components.
The total number of lymphocytes and NK cells does not change with age, but how well they function does.
The immune system can begin attacking itself, a condition called autoimmunity.
Psychoneuroimmunology is the study of the rela- tions between psychological, neurological, and immunological systems that raise or lower our sus- ceptibility to and ability to recover from disease.
HIV and AIDS are growing problems among older adults.
What are the developmental trends in chronic and acute diseases?
Acute diseases are conditions that develop over a short period of time and cause a rapid change in health. Chronic diseases are conditions that last a longer period of time (at least 3 months) and may be accompanied by residual functional impairment that necessitates long-term management.
The incidence of acute disease drops with age, but the effects of acute disease worsen. The incidence of chronic disease increases with age.
What are the key issues in stress across adulthood? The stress and coping paradigm views stress, not as
an environmental stimulus or as a response, but as the interaction of a thinking person and an event.
Primary appraisal categorizes events into three groups based on the significance they have for our well-being: irrelevant, benign or positive, and stressful. Secondary appraisal assesses our ability to cope with harm, threat, or challenge. Reap- praisal involves making a new primary or secondary appraisal that results from changes in the situation.
Attempts to deal with stressful events are called coping . Problem-focused coping and emotion- focused coping are two major categories. People also use religion as a source of coping.
There are developmental declines in the number of stressors and in the kinds of coping strategies people use.
Stress has several negative consequences for health.
4.3 Common Chronic Conditions and Their Management
What are the most important issues in chronic disease? Chronic conditions are the interaction of biological,
psychological, sociocultural, and life-cycle forces. What are some common chronic conditions across
adulthood? Arthritis is the most common chronic condition.
Arthritis and osteoporosis can cause mild to severe impairment.
Cardiovascular and cerebrovascular diseases can create chronic conditions after stroke.
Diabetes mellitus occurs when the pancreas produces insufficient insulin. Although it cannot be cured, it can be managed effectively. However, some serious problems, such as diabetic retinopathy, can result.
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124 CHAPTER 4
Many forms of cancer are caused by lifestyle choices, but genetics also plays an important role. The risk of developing cancer increases markedly with age. Prostate and breast cancer involve diffi- cult treatment choices.
For many people, the inability to control the elimi- nation of urine and feces on an occasional or con- sistent basis, called incontinence, is a source of great concern and embarrassment. Effective treat- ments are available.
How can people manage chronic conditions? Effective pain management can be achieved
through pharmacological and nonpharmacological approaches. Pain is not a normal outcome of aging and is not to be dismissed.
4.4 Pharmacology and Medication Adherence
What are the developmental trends in using medication?
Older adults use nearly half of all prescription and over-the-counter drugs. The average older adult takes six or seven medications per day. However, the general lack of older adults in clinical tri- als research means we may not know the precise effects of medications on them.
How does aging affect the way that medications work?
The speed with which medications move from the stomach to the small intestine may slow with age. However, once drugs are in the small intes- tine, absorption rates are the same across adult- hood.
The distribution of medications in the bloodstream changes with age.
The speed of drug metabolism in the liver slows with age.
The rate at which drugs are excreted from the body slows with age.
What are the consequences of medication interactions?
Older adults are more prone to harmful side effects of medications.
Polypharmacy is a serious problem in older adults and may result in serious drug interactions.
What are the important medication adherence issues?
Polypharmacy leads to lower rates of correct adherence to medication regimens.
4.5 Functional Health and Disability
What factors are important to include in a model of disability in late life?
Disability is the effects of chronic conditions on people’s ability to engage in activities in daily life.
A model of disability includes pathology, impair- ments, functional limitations, risk factors, extrain- dividual factors, and intraindividual factors. This model includes all four main developmental forces.
What is functional health? Frail older adults are those who have physical dis-
abilities, are very ill, or may have cognitive or psy- chological disorders and who need assistance with everyday tasks.
Activities of daily living (ADLs) include basic self- care tasks such as eating, bathing, toileting, walk- ing, and dressing.
Instrumental activities of daily living (IADLs) are actions that entail some intellectual competence and planning.
Rates of problems with ADLs and IADLs increase dramatically with age.
What causes functional limitations and disability in older adults?
The chronic conditions that best predict future dis- ability are arthritis and cerebrovascular disease. Other predictors include smoking, heavy drinking, physical inactivity, depression, social isolation, and fair or poor perceived health.
Being wealthy helps increase average longevity but does not protect one from developing chronic con- ditions, meaning that such people may experience longer periods of disability late in life.
Women’s health generally is poorer across cultures, especially in developing countries.
Ethnic group differences are also important. The validity of measures of functioning sometimes dif- fers across ethnicity and gender.
Review Questions 4.1 How Long Will We Live?
What is the difference between average longevity and maximum longevity?
What genetic and environmental factors influence average longevity?
What ethnic and gender differences have been found?
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LONGEVITY, HEALTH, AND FUNCTIONING 125
4.2 Health and Illness How are the definitions of health and illness linked? How is quality of life defined generally, especially
in relation to health? What are the major age-related changes in the
immune system? How do they affect health and ill- ness?
What is the difference between acute and chronic diseases? How do the rates of each change with age?
How does the stress and coping paradigm explain the experience of stress? What age-related changes occur in the process?
4.3 Common Chronic Conditions and Their Management
What are the general issues to consider in manag- ing chronic disease?
What are some common chronic diseases experi- enced by older adults?
How is pain managed?
4.4 Pharmacology and Medication Adherence What is the typical pattern of medication use in
older adults? What changes occur with age that influence how
well medications work? What are the major risks for side effects and drug
interactions? How can adherence to medication regimens be
improved?
4.5 Functional Health and Disability What are the key components in a model of dis-
ability in older adults? What are ADLs and IADLs? How does the number
of people needing assistance change with age? What conditions result in disability most often? How do socioeconomic status, ethnicity, and gen-
der affect health and disability?
INTEGRATING CONCEPTS IN DEVELOPMENT What physiological changes described in Chapter 2
are important in understanding health? Based on information in Chapters 2 and 3 , how
might a primary prevention program be designed
to prevent cardiovascular disease? (Compare your answer with the intervention types described in Chapter 5 .)
How do the ethnic differences in average longevity and in health relate to the diversity issues we exam- ined in Chapter 1 ?
KEY TERMS absorption The time needed for a medication to enter a patient’s bloodstream.
active life expectancy The age to which one can expect to live independently.
activities of daily living (ADLs) Basic self-care tasks such as eating, bathing, toileting, walking, and dressing.
acute diseases Conditions that develop over a short period of time and cause a rapid change in health.
autoimmunity The process by which the immune sys- tem begins attacking the body.
average longevity The length of time it takes for half of all people born in a certain year to die.
chronic diseases Conditions that last a longer period of time (at least 3 months) and may be accompanied by residual functional impairment that necessitates long-term management.
compression of morbidity The situation in which the average age when one becomes disabled for the first time is postponed, causing the time between the onset of disability and death to be compressed into a shorter period of time.
coping In the stress and coping paradigm, any attempt to deal with stress.
dependent life expectancy The age to which one can expect to live with assistance.
diabetes mellitus A disease that occurs when the pan- creas produces insufficient insulin.
disability The effects of chronic conditions on people’s ability to engage in activities that are necessary, expected, and personally desired in their society.
drug excretion The process of eliminating medica- tions, usually through the kidneys in urine, but also through sweat, feces, and saliva.
drug metabolism The process of getting rid of medica- tions in the bloodstream, partly in the liver.
emotion-focused coping A style of coping that involves dealing with one’s feelings about the stressful event.
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126 CHAPTER 4
exacerbators Situations that makes a situation worse than it was originally.
frail older adults Older adults who have physical disabilities, are very ill, and may have cognitive or psychological disorders and need assistance with everyday tasks.
functional health status How well a person is functioning in daily life.
functional incontinence A type of incontinence usually caused when the urinary tract is intact but due to physical disability or cognitive impairment the person is unaware of the need to urinate.
health The absence of acute and chronic physical or mental disease and impairments.
Illness The presence of a physical or mental disease or impairment.
incontinence The loss of the ability to control the elimination of urine and feces on an occasional or consistent basis.
instrumental activities of daily living (IADLs) Actions that entail some intellectual competence and planning.
maximum longevity The maximum length of time an organism can live—roughly 120 years for humans.
overflow incontinence A type of incontinence usually caused by improper contraction of the kidneys, causing the bladder to become overdistended.
polypharmacy The use of multiple medications.
primary appraisal First step in the stress and cop- ing paradigm in which events are categorized into three groups based on the significance they have for our well-being—irrelevant, benign or positive, and stressful.
problem-focused coping A style of coping that attempts to tackle a problem head-on.
psychoneuroimmunology The study of the relations between psychological, neurological, and immunologi- cal systems that raise or lower our susceptibility to and ability to recover from disease.
reappraisal In the stress and coping paradigm, this step involves making a new primary or secondary appraisal resulting from changes in the situation.
risk factors Long-standing behaviors or conditions that increase one’s chances of functional limitation or disability.
secondary appraisal In the stress and coping para- digm, an assessment of our perceived ability to cope with harm, threat, or challenge.
stress and coping paradigm A model that views stress, not as an environmental stimulus or as a response, but as the interaction of a thinking person and an event.
stress incontinence A type of incontinence that happens when pressure in the abdomen exceeds the ability to resist urinary flow.
Type I diabetes A type of diabetes that tends to develop earlier in life and requires the use of insulin; also called insulin-dependent diabetes.
Type II diabetes A type of diabetes that tends to develop in adulthood and is effectively managed through diet.
urge incontinence A type of incontinence usually caused by a central nervous system problem after a stroke or urinary tract infection in which people feel the urge to urinate but cannot get to a toilet quickly enough.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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Where People Live: Person–Environment Interactions
5.1 DESCRIBING PERSON–ENVIRONMENT INTERACTIONS Competence and Environmental Press • Discovering Development: What’s Your Adaptation Level? • Preventive and Corrective Proactivity (PCP) Model • Stress and Coping Framework • Common Theoretical Themes and Everyday Competence
5.2 THE ECOLOGY OF AGING: COMMUNITY OPTIONS Aging in Place • Deciding on the Best Option • Home Modification • Adult Day Care • Congregate Housing • Assisted Living
5.3 LIVING IN NURSING HOMES Types of Nursing Homes • Current Controversies: Financing Long-Term Care • Who Is Likely to Live in Nursing Homes? • Characteristics of Nursing Homes • Special Care Units • Can a Nursing Home Be a Home? • Communicating with Residents • How Do We Know?: Identifying Different Types of Elderspeak in Singapore • Decision-Making Capacity and Individual Choices • New Directions for Nursing Homes
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 5
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128 CHAPTER 5
You encounter them every day— devices such as grip bars in bathrooms, wider doorways, and ramps leading to building entrances. You may not pay much attention to them and even take them for grant- ed, but these environmental modifications mat- ter. They may mean the difference between living independently and living somewhere else. Sup- portive environments for adults, especially older adults with significant physical or cognitive impair- ment, are key to providing continuing quality of life. Research on how people deal with the settings where they reside has revolutionized the way we design houses and care facilities. The rapidly increasing need for alternatives to nursing homes has resulted in the creation of a wide range of options for families. These changes began with the simple observation that behavior is a function of the environment in which it occurs and the interac- tion with the individual’s personal characteristics.
In this chapter, we explore how differences in the interaction between personal character- istics and the living environment can have pro- found effects on our behavior and feelings about ourselves. Several theoretical frameworks are described that help us understand how to interpret person–environment interactions in a develop- mental context. Next, we consider the ecology of aging and discover how people can age in place, along with the support systems that underpin that goal. We consider the role of adult day care and
several housing options that help people stay in the community as much as possible. Because some people need intensive support, we take a close look at nursing homes. Sometimes we must con- sider the person separately from the environment, but keep in mind throughout the chapter that in the end it is the interaction of the two we want to understand.
5.1 Describing Person–Environment Interactions LEARNING OBJECTIVES
What is the competence and environmental press model?
What is the preventive and corrective proactivity (PCP) model?
What are the major aspects of stress and coping theory relating to person–environment interactions?
What are the common themes in the theories of person–environment interactions?
Hank has lived in the same poor neighborhood all of his 75 years. He has lived alone for the past several months since his wife, Marilyn, had a stroke and was placed in a nursing home. Hank’s oldest daughter expressed concern about her father and has been pressing him to move in with her. Hank is reluctant; he likes knowing his neigh- bors, shopping in familiar stores, and being able to do what he wants. He wonders how well he could adapt to living in a new neighborhood after all these years. He realizes it might be easier for him to cope if he lived with his daughter, but it’s a tough decision.
To appreciate the roles different environments play in our lives, we need a framework for interpreting how people interact with them. Theories of person– environment interactions help us understand how people view their environments and how these views may change as people age. These views have been described since the 1930s and have significant impact on the study of adults (Pynoos, Caraviello, & Cicero, 2010). We consider four that affect views of adult development and aging: competence and environmen- tal press, congruence, stress and coping, and everyday competence.
All these theories can be traced to a common beginning. In 1936, Kurt Lewin con ceptualized
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 129
person–environment interactions in the equation: B = f ( P , E ) . This relationship defining person–environment interactions means behavior (B) is a function of both the person (P) and the environment (E). More recent theorists took Lewin’s equation and described the components in the equation in more detail. Specifi- cally, their speculations concern the characteristics of people and environments that combine to form behavior.
Most of these models emphasize the importance of people’s perceptions of their environments. Although objective aspects of environments (i.e., crime, housing quality) are important, personal choice plays a major role. For example, many people deliberately choose to live in New York or Atlanta, even though certain crime rates in those cities are higher than in Selma or Walla Walla. The importance of personal perception in envi- ronments is similar to the role of personal perception in social cognition and in concepts such as personal control (see Chapter 9 ). As you will see, these ideas, especially the notion of personal control, are included in many approaches to understanding person–envi- ronment interactions.
Competence and Environmental Press Understanding psychosocial aging requires attention to individuals’ needs rather than treating all older adults alike. One method focuses on the relation between the person and the environment (Aldwin & Igarashi, 2012). The competence–environmental press approach is a good example of a theory incorporat- ing elements of the biopsychosocial model into the person–environment relation (Lawton & Nahemow, 1973; Nahemow, 2000; Pynoos et al., 2010).
Competence is defined as the upper limit of a per- son’s ability to function in five domains: physical health, sensory-perceptual skills, motor skills, cognitive skills, and ego strength. These domains are viewed as under- lying all other abilities and reflect the biological and psychological forces. Environmental press refers to the physical, interpersonal, or social demands that environ- ments put on people. Physical demands might include having to walk up three flights of stairs to your apart- ment. Interpersonal demands may require adjusting your behavior patterns to different types of people. Social demands involve dealing with laws or cus- toms that place certain expectations on people. These
aspects of the theory reflect biological, psychological, and social forces. Both competence and environmen- tal press change as people move through the life span; what you are capable of doing as a 5 -year-old differs from what you are capable of doing as a 25 - , 45 - , 65 - , or 85 -year-old . Similarly, the demands put on you by the environment changes as you age. Thus, the competence–environmental press framework reflects life-cycle factors as well.
The competence and environmental press model depicted in Figure 5.1 shows how the two are related. Low to high competence is represented on the verti- cal axis, and weak to strong environmental press is
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Figure 5.1 Behavioral and emotional outcomes of person– environment interactions are based on the competence and environmental press model. This figure indicates a person of high competence will show maximum performance over a larger range of environmental conditions than will a person with lower levels of competence. The range of optimal environments occurs at a higher level of environmental press (A) for the person with the most competence than it does for the person with the lowest level of competence (B). Source: Lawton, M. P. & L. Nahemow. Ecology of the Aging Process. In C. Eisdorfer & M. P. Lawton (Eds.), The Psychology of Adult Development and Aging, p. 661.
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displayed on the horizontal axis. Points in the fig- ure represent various combinations of the two. Most important, the shaded areas show adaptive behavior and positive affect can result from many different combinations of competence and environmental press levels. Adaptation level is the area where press level is average for a particular level of competence; this is where behavior and affect are normal. Slight increases in press tend to improve performance; this area on the figure is labeled the zone of maximum performance potential. Slight decreases in press create the zone of maximum comfort, in which people are able to live happily without worrying about environmental demands. Combinations of competence and environmental press that fall within either of these two zones result in adaptive behavior and positive emotion that translate into a high quality of life.
As a person moves away from these areas, behavior becomes increasingly maladaptive and affect becomes negative. Notice that these outcomes can result from several different combinations and for different rea- sons. For example, too many environmental demands on a person with low competence and too few demands on a person with high competence both result in mal- adaptive behaviors and negative emotion.
What does this mean with regard to late life? Is aging merely an equation relating certain variables? The important thing to realize about the competence– environmental press model is that each person has the potential of being happily adapted to some living situations, but not to all. Whether people function well depends on if what they are able to do fits what the environment forces them to do. When their abilities match the demands, people adapt; when there is a mis- match, they don’t. In this view, aging is more than an equation, because the best fit must be determined on an individual basis.
How do people deal with changes in their par- ticular combinations of environmental press (such as adjusting to a new living situation) and competence (perhaps reduced abilities due to illness)? People respond in two basic ways (Lawton, 1989; Nahemow, 2000). When people choose new behaviors to meet new desires or needs, they exhibit proactivity and exert con- trol over their lives. In contrast, when people allow the situation to dictate the options they have, they demon- strate docility and have little control. Lawton (1989)
argues that proactivity is more likely to occur in people with relatively high competence, and docility in people with relatively low competence.
The model has considerable research support. For example, the model accounts for why people choose the activities they do (Lawton, 1982), how well peo- ple adhere to medication regimens (LeRoux & Fisher, 2006), and how they adapt to changing housing needs over time (Iwarsson, Slaug, & Fänge, 2012; Pynoos, Steinman, Do Nguyen, & Bressette, 2012). This model helps us understand how well people adapt to various care settings, (Golant, 2012; Moore, 2005). In short, there is considerable merit to the view that aging is a complex interaction between a person’s competence level and environmental press, mediated by choice. This model can be applied in many different settings.
As an example of the Lawton and Nahemow model, consider Rick. Rick works in a store in an area of Chi- cago where the crime rate is moderately high, represent- ing a moderate level of environmental press. Because he is good at self-defense, he has high competence; thus he manages to cope. Because the Omaha police chief wants to lower the crime rate in that area, she increases patrols, thereby lowering the press level. If Rick main- tains his high competence, maladaptive behavior may result because he has more competence than is optimal for the new environment. But if a street gang moved in instead of the police, Rick would have to increase his competence and be more prepared to maintain his adaptation level. Other changes in the environment (such as arson threats) or in his competence (such as a broken arm) would create different combinations.
Before leaving Lawton and Nahemow’s model, we need to note an important implication for aging. The less competent the person is, the greater the impact of environmental factors. To the extent people expe- rience declines in health, sensory processes, motor skills, cognitive skills, or ego strength, they are less able to cope with environmental demands. Personal competence predicts how well older adults adapt after being discharged from a hospital or when pro- vided assistive technology (Lichtenberg et al., 2000; Peterson, Prasad, & Prasad, 2012). Thus, for older adults to maintain good adaptational levels, changes to lower environmental press or raise competence are needed. This point is made clearer in the Discovering Development feature. Take some time to complete it.
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 131
Because most older adults prefer to live at home, assessing competence and environmental press in that context is very important (Chin & Quine, 2012; Iwarsson et al., 2012). Given the importance of mak- ing as many living arrangement options available as possible, it is critical we understand how the envi- ronment affects people’s day-to-day functioning in them. For example, the changing balance between competence and environmental press is a major fac- tor in older adults’ decisions to relocate (Sergeant & Ekerdt, 2008). Additionally, the competence and envi- ronmental press model has been the basis for evaluat- ing and optimizing living situations with people who have severe cognitive impairments, such as those of Alzheimer’s disease (Dalton & Harrison, 2012). To manage severe cognitive impairment effectively, care- givers must identify the right level of environmental support based on the patient’s level of competence.
For example, people with mild cognitive impair- ment may be able to live independently, but as the impairment increases additional levels of support are needed. The model has provided the basis for design- ing special care units for people with Alzheimer’s dis- ease. In these units, environmental supports such as color-coded room doors, help people with dementia identify where they belong.
Preventive and Corrective Proactivity (PCP) Model
Maintaining a high quality of life is a key goal for adults of all ages. From the competence-environmental press approach we saw proactivity, exerting control over one’s life, is central to achieving that goal. Because pro- activity is so important, Kahana and Kahana (2003; Kahana, Kahana, & Zhang, 2006) built a model of suc- cessful aging on the core concept of proactivity. The model is shown in Figure 5.2 .
The PCP model explains how life stressors (such as life events, chronic illnesses) and lack of good con- gruence in person–environment interactions (Compo- nent B), especially when the person has nothing to help buffer or protect against these things, result in poor life outcomes (Component F). The helpful buffers include external resources (Component E) such as friends or home modifications, internal resources or dispositions (Component C) such as a positive outlook on life, and specific proactive behaviors (Component D), such as physical exercise, work to lower the negative impact of the stressors and prepare people to cope better in the future. In brief, the PCP model proposes proactive adaptations and helpful external resources reduce the effect of life stressors on quality-of-life outcomes.
What kinds of actions reflect proactive adapta- tions? Kahana et al. (2006) described two types of proactive adaptations: preventive and corrective. Preventive adaptations are actions that avoid stressors and increase or build social resources. An example of a preventive adaptation would be increasing one’s social network by adding friends. Corrective adaptations are actions taken in response to stressors and can be facili- tated by internal and external resources. An example of a corrective adaptation is changing one’s diet after hav- ing a heart attack.
Older adults tend to engage in more correc- tive adaptations than preventive adaptations, at least
DISCOVERING DEVELOPMENT: WHAT’S YOUR ADAPTATION LEVEL? Lawton and Nahemow’s competence and environ- mental press model has wide applicability, as indi- cated in the examples of Hank and Rick. The model provides an excellent introduction to the impor- tance of considering people’s capabilities and the environmental demands made of them. To under- stand how the model works, consider yourself. Make a list of the different aspects of your life, such as school, social activities, work, and so forth. Think about each of these areas and rate yourself in terms of your abilities. For example, in the case of school, consider each course you are taking and rate how capable you are in each. Then consider the number and kinds of demands made on you in each area. For instance, think about the many demands put on you in each course. Now look at how the rating of your competence intersects with the kinds and number of demands. Does it place you in the posi- tion of feeling bored? In this case, you would fall in the left side of the graph. Are you feeling stressed out and under pressure? Then you would fall on the right side of the graph. Feeling just about right? You’ve experienced your adaptation level. Doing this analysis for the various aspects of your life will help you understand why you feel more competent in some areas than others.
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initially. However, many actions that start as corrective adaptations turn into preventive adaptations. A great example of this is exercise. Many people begin an exer- cise program only after they are told to, perhaps as part of a recovery regimen after a health crisis. However, continued exercise becomes preventive by helping the person avoid future recurrences of the original health problem and avoid other problems altogether.
Research supports the importance of proactiv- ity as described in the PCP model. Kahana, Kelley- Moore, & Kahana (2012) showed life stressors can still have a negative effect on quality-of-life outcomes four years after they occur, but proactive adaptations (such as exercise, planning ahead, and gathering support) significantly reduce this negative impact. Longitudi- nal research in China also showed the importance of
proactivity and other external and internal resources in improving quality-of-life outcomes in the oldest old residents in the community and in long-term care facilities (Liu, Dupre, Gu, Mair, & Chen (2012).
We consider the PCP model again in Chapter 14 when we focus specifically on successful aging. In the meantime, keep it in mind as you learn about specific behaviors and situations that help people adapt suc- cessfully to the changes that occur with age.
Stress and Coping Framework As you know from your own experience, sometimes your interaction with the environment is stressful. Schooler (1982) has applied Lazarus and Folkman’s cog- nitive theory of stress and coping, described in Chapter 4 , to the understanding of the older person’s interaction
(A) TEMPORAL AND SPATIAL CONTEXT
(B) CUMULATIVE STRESS EXPOSURE
(D) PROACTIVE ADAPTATIONS
(E) EXTERNAL RESOURCES
(F) QUALITY-OF-LIFE OUTCOMES
Financial Resources
Social Resources
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Path 3
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Path 2a
Path 2b
Path 7
Path 1
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Path 6a
Path 6b
Path 5 Maintenance of
Valued Activities and Relationships
Meaning in Life
Affective States
Long-Term Events
Recent Events Chronic Illness Social Losses
Person–Environment Incongruence
Traditional Preventive Adaptations
Health Promotion (exercise) Planning Ahead
Helping Others
Traditional Corrective Adaptations
Marshalling Support Role Substitution Environmental
Modifications
Emergent Adaptations Preventive and Corrective
Technology Use Health Care Consumerism
Self Improvement
Emergent Resources Access to Technology Access to Health Care
(C) INTERNAL RESOURCES/DISPOSITIONS OF SUCCESSFUL AGING
Future Orientation
Hopefulness Self-Esteem
Life Satisfaction Altruism Coping
Dispositions
Temporal context of history and biography
Spatial context of demography and
community
Figure 5.2 Model of emerging proactive options for successful aging. Source: Kahana, E., Kahana, B., & Zhang, J. (2006). Motivational antecedents of preventive proactivity in late life: Linking future orientation and exercise. Motivation and Emotion , 29, 438–459 (Figure 1). DOI: 10.1007/s11031-006-9012-2. Retrieved from http://www.springerlink.com/content/61304201gm163778// fulltext.html#Fig1 .
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 133
with the environment. The basic premise of Lazarus’ theory is that people evaluate situations to assess their potential threat value. Situations can be evaluated as harmful, beneficial, or irrelevant. When situations are viewed as harmful or threatening, people also establish the range of coping responses they have at their disposal for avoiding the harmful situation. This process results in a coping response. Outcomes of coping may be posi- tive or negative depending on many contextual factors.
Schooler (1982) argues this perspective is espe- cially helpful in understanding older adults like Hank because of their greater vulnerability to social and phys- ical hazards. To test his ideas, Schooler evaluated retest data on a sample of 521 people drawn from a national sample of 4 , 000 older adults living in long-term care facilities. In particular, he examined the impact of three potential stressors (environmental change, residential mobility, and major life events) on health or morale. He also examined the buffering, or protective effects of social support systems and ecological factors on the relationships between the stressors and outcomes. Con- sistent with the theory, Schooler showed the presence of social support systems affected the likelihood that particular situations would be defined as threatening. For example, living alone is more likely to be viewed as stressful when people have little social support than when they have many friends who live nearby.
Schooler’s initial work provides an important theo- retical addition because it deals with the relation between everyday environmental stressors and the adaptive response of community-dwelling individuals. His ideas have been extended to other contexts. When certified nurse aides (CNAs) working in nursing homes were pro- vided with training and empowered as a way to deal with environmental stressors, the result was better care for residents, better cooperation between CNAs and nurses, and reduced turnover (Yeatts & Cready, 2008). Caregiv- ers of persons with dementia also show resilience when they have effective ways of dealing with environmental stressors (Gaugler, Kane, & Newcomer, 2007).
Common Theoretical Themes and Everyday Competence
The three theories we have considered have much in common. Most important, all agree the focus must be on the interaction between the person and the envi- ronment, not on one or the other. Another important
common theme is no single environment meets every- one’s needs. Rather, a range of potential environments may be optimal.
Several researchers built on these ideas and focused on people’s everyday competence (e.g., Heyl & Wahl, 2012; Lou & Ng, 2012). Everyday competence is a per- son’s potential ability to perform a wide range of activi- ties considered essential for independent living; it is not the person’s actual ability to perform the tasks. Everyday competence also involves a person’s physical, psycho- logical, and social functioning, that interact in complex ways to create the person’s day-to-day behavior. Lou & Ng (2012) showed cognitive competence, closeness to family, and relationship-based coping are helping Chi- nese older adults who live alone deal effectively with loneliness. Additionally, an older person’s competence in the psychological domain includes cognitive problem- solving abilities, beliefs about personal control and self- efficacy, and styles of coping (Diehl et al., 2005, 2012).
Although everyday competence is most often con- sidered in the context of activities of daily living (ADLs) and instrumental activities of daily living (IADLs; see Chapter 4 ), it can also be considered more broadly. The reason is a behavior must not be viewed in isolation; behavior is expressed in a particular environmental context. In particular, researchers and clinicians need to be sensitive to cultural and contextual differences in everyday competence across different environments (Diehl et al., 2005, 2012).
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Using these ideas, Willis (1991, 1996a; Allaire & Willis, 2006; Jones et al., 2012; Schaie & Willis, 1999) developed a model of everyday competence incorporat- ing all the key ideas discussed earlier. Willis distinguishes between antecedents, components, mechanisms, and outcomes of everyday competence. Antecedents include both individual (e.g., health, cognition) and sociocul- tural (e.g., cultural stereotypes, social policy, health care policy) factors. These influence the intraindividual and contextual components, the particular domains and contexts of competence. Which components are most important or exert the most influence depends on the overall conditions under which the person lives. These elements of the model reflect the basic ideas in both the competence and environmental press model and the person-environment model we considered ear- lier. The mechanisms involve factors that moderate the way competence is actually expressed; such as whether one believes he or she is in control of the situation, influ- ences how competent the person turns out to be. Finally, the model proposes the primary outcomes of everyday competence are psychological and physical well-being, two of the major components of successful aging.
Understanding the complexities of everyday com- petence is important as a basis for considering whether people, especially some older adults, are capable of making certain decisions for themselves. This issue often arises in terms of competence to make key health care and other decisions, a topic we consider in more detail later in this chapter. Willis’ model also points out the health outcomes of one episode of everyday com- petence are the antecedents of the next, illustrating how future competence is related to current compe- tence. Research on cognitive training from this per- spective shows that training on reasoning, maintained over time, can attenuate age-related change (Jones et al., 2012). Finally, decline in older adults’ ability to handle everyday problems predicts mortality, indicat- ing everyday competence may be a reasonable indica- tor of health status (Allaire & Willis, 2006).
All of this research supports the idea that older adults can age in place to the extent their everyday competence permits. Aging in place requires whatever necessary services and supports an older adult needs in order to live in the community be provided or made available. This approach has been adopted by govern- ments (e.g., Australia in relation to disability; Bigby,
2008; Disability Policy Research Working Group, 2011), and is the goal for much of the smart technology available for older adults, such as cognitive wellness systems (Meza-Kubo & Morán, in press). We consider aging in place in more detail in the next section.
Adult Development in Action How would a thorough understanding of compe- tence and environmental press influence your work as a housing planner for older adults?
5.2 The Ecology of Aging: Community Options LEARNING OBJECTIVES
What is aging in place? How do people decide the best option? How can a home be modified to provide a
supportive environment? What options and services are provided in adult
day care? What is congregate housing? What are the characteristics of assisted living?
M ark was diagnosed as having vascular dementia about six months ago. Because he now has difficulty in remem- bering to turn off his gas stove, his daughter and son- in-law think it may be best for him to move into an assisted living facility. They had Mark evaluated by his physician, who indicates she thinks for safety reasons assisted living is a good idea, especially because Mark’s family lives several hundred miles away.
Most people go through young adulthood, middle age, and into later life performing routine daily tasks without much thought. As we grow older, the norma- tive changes that occur often result in more challenges in dealing with environments that were once not a problem at all. Even our homes, formerly a comfort- able supportive place, can present difficult challenges; the walk up the stairs to a bedroom may become an equivalent of climbing a mountain.
Mark is typical of a growing number of older adults in the United States and other countries—he experiences a significant decline in function, lives alone, and his adult child and family live in another
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 135
city some distance away. As a result, he, like many older adults, needs a different living situation. He does not need full-time nursing care at this point, but does need a more supportive environment.
Changes in functional status and how these changes are helped or hurt by the environments we live in are an important aspect of the experience of grow- ing older for many people. These changes are studied in a field called the ecology of aging or environmental psychology, which seeks to understand the dynamic rela- tions between older adults and the environments they inhabit (Scheidt & Schwarz, in press). It is important to understand how seemingly small changes in a person’s environment can result in major changes in behavior, changes that can make the difference between a per- son being able to live independently or needing a more supportive situation.
In this section, we consider options for older adults that help them maintain as much independence as pos- sible. First, we evaluate the concept of aging in place. Then we present three approaches to helping people live in the community as long as possible: home modifica- tion, and two living situations that provide various lev- els of support—congregate housing and assisted living.
Aging in Place Imagine you are an older adult who has difficulty cooking meals and getting around. If you had a choice of where you wanted to live, where would it be? Maybe some of your family members urge you to move to a place where your meals are provided and you can be driven where you need to go, while others suggest you to stay in your own place even though there will be challenges. What do you do?
Based on the competence–environmental press model described earlier, older adults have options (Scheidt & Schwarz, 2010). As the environment in which one lives becomes more restrictive, many older adults engage in selection and compensation to cope. They may select a different place to live or they may adapt their behaviors in order to compensate for their limitations, such as using microwaveable prepared foods instead of cooking meals from scratch. Using a cane or other device to assist in walking is another example of compensation.
The idea of aging in place reflects a balanc- ing of environmental press and competence through
selection and compensation. Being able to maintain one’s independence in the community is often impor- tant for people, especially in terms of their self-esteem and ability to continue engaging in meaningful ways with friends, family, and others. This is important psychologically (Rowles, Oswald, & Hunter, 2004). Older adults who age in place form strong emotional and cognitive bonds with their residences that help transform a “house” into a “home.” Having a “home” provides a strong source of self-identity.
Throughout adulthood, people adapt to changes in the places where they live, sometimes severing con- nections with past settings (Rowles & Watkins, 2003). Making a change in where people live, and having to psychologically disconnect with a place where they may have lived for many decades, can be difficult and traumatic. There is no question people develop attach- ments to place, deriving a major portion of their iden- tity from it and feeling they own it.
Rowles (2006) discusses the process of how a place becomes a home. Because of the psychological con- nections, the sense that one is “at home” becomes a major concern in relocation, especially if the relocation involves giving up one’s home. Later in this chapter, we consider how a nursing home might become a home, but for now the important idea is that a key factor is a sense of belonging.
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136 CHAPTER 5
Feeling one is “at home” is a major aspect of aging in place. Providing older adults a place to call their own that supports the development of the psychological attachments necessary to convert the place to a home is key for successful aging in place (Scheidt & Schwarz, 2010). Aging in place provides a way for older adults to continue finding aspects of self-identity in where they live, and to take advantage of support systems that are established and familiar.
The growing understanding of the importance of aging in place has resulted in a rethinking of cer- tain housing options that provide a way for frail older adults to stay in their communities. Such options are important for fragile older adults who are poor and cannot afford more expensive formal assisted living or nursing home facilities (discussed later). One alter- native is cluster housing that combines the aging in place philosophy with supportive services (de Jong, Rouwendal, van Hattum, & Brouwer, 2012; Golant, 2008).
Golant (2008) describes several types of affordable cluster housing care. A key feature is that services are provided to the residents by staff hired by the owner or a service provider under contract. These services might range from having only a service case manager or to actually providing information, caregiving assis- tance (e.g., meals, housekeeping), transportation, or health care. The aging in place philosophy in these set- tings emphasizes individual choice on the part of resi- dents in terms of what services to use. This approach is being adopted in other countries, such as the Nether- lands (de Jong et al., 2012).
Although cluster housing and other approaches to aging in place make sense as lower-cost alternatives to nursing homes that keep people in their commu- nities, affording them is often difficult. Unlike long- term care facilities, cluster housing developments are not covered by Medicaid or other insurance. Finding solutions to the funding issue will be an important aspect for keeping costs down and providing support- ing environments for older adults who need support. For many, making modifications to their existing housing represents a more cost-effective option, and provides a research-based way to remain in a familiar environment. We consider this approach later in this section.
Deciding on the Best Option One of the most difficult decisions individuals and families have to make is where an older member should live. Such decisions are never easy and can be quite wrenching. Figuring out the optimal “fit” where the individual’s competence and the environmental press are in the best balance rests on the ability of all concerned to be objective about the individual’s com- petence and the ability of the lived-in environment to provide the level of support necessary. This balance requires a degree of honesty in communication with all family members that is sometimes challenging.
There are several key decision points in addressing the issue of the optimal housing environment. First, it must be determined whether the individual has signif- icant cognitive or physical impairment requiring inter- vention or support. Next, an assessment of the ability of family members or friends to provide support or care must be made. Once that information is understood, a series of decisions can be made about the best way to provide the necessary environmental supports to cre- ate the optimal “fit.” Assuming all information shows the need for some sort of intervention, the next criti- cal decision is whether there is an option for providing that intervention in the current home situation or if other options need to be pursued. Later, we consider several living options for individuals needing support ranging from minor modifications of the present home to skilled care nursing homes.
Throughout this process, the individual in ques- tion needs to be an integral part of decision making to the extent possible. This is especially important when the outcome is likely to be a placement that involves moving from the person’s current residence. The degree the person actually understands the options available, why the options are being pursued, and the long-term meaning of the decision being considered is an integral part of the person’s right to determine his or her own life outcome (a point considered in more detail later).
Individuals and families facing these decisions should consult with the person’s physician after a thor- ough diagnostic evaluation. Additionally, objective information about available housing options can be obtained from local senior centers, offices on aging, and other nonprofit service providers.
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 137
Home Modification The competence–environmental press model provides two options for people who experience difficulties dealing with the tasks of daily life. On one hand, people can increase their competency and develop better or new skills for handling. To better remember where you put your car keys, you can learn a new memory strat- egy. On the other hand, people can lower the environ- mental press by modifying the environment to make the task easier; putting a hook for the car keys next to the door you exit so you see them on your way out.
These two options represent applications of theory to real-world settings that also apply to helping people deal with the challenges they face in handling tasks of daily living in their homes. When it comes to these kinds of issues, the most frequent solution involves modifying one’s home (i.e., changing the environ- ment) in order to create a new optimal balance or bet- ter “fit” between competence and environmental press (Scheidt & Schwarz, 2010).
Many strategies are available for modifying a home to help a person accommodate changing competen- cies. Minor structural changes, such as installing assis- tive devices (e.g., hand rails in bathrooms and door handles that are easier to grip), are common strategies. In other cases, more extensive modifications may be needed to make a home fully accessible, such as widen- ing doorways, lowering countertops, and constructing wheelchair ramps.
Although minor alterations can often be done at low cost, more extensive modifications needed by people with greater limitations may be unaffordable for low-income individuals. Even though the cost of such interventions is significantly lower than placement in long-term care facilities or assisted living, many peo- ple simply cannot afford them. As a result, many older adults with functional impairments experience a mis- match between their competency and their environ- ment (Iwarsson et al., 2012; Wahl, Fänge, Oswald, Gitlin, & Iwarsson, 2009; Wahl, Iwarsson, & Oswald, 2012).
Research indicates home modifications done to address difficulties with accomplishing activities of daily living (ADLs) typically reduce disability-related outcomes (Iwarsson et al., 2012; Wahl et al., 2009, 2012). Whether these modifications help older adults who are prone to falling remains inconclusive.
An emerging high-tech approach to home modi- fication is the auxiliary dwelling unit (ADU). The ADU is a portable hospital room that is a separate dwelling placed next to a family’s main dwelling to give an older relative both privacy and proximity to family (Kunkle, 2012). Colloquially known as granny pods , the dwelling contains a number of “smart” devices that do everything from serving as a virtual companion, providing special knee-level lighting to reduce the risk of falls, and offering better mobility through ceiling mounted lifts. A diagram of a typical unit is shown in Figure 5.3.
The advantage to ADUs is that they can be as tem- porary or permanent as needed, and they provide both independence and support for aging in place. As tech- nology improves, it is likely solutions like ADUs will increase in popularity and decrease in cost.
Adult Day Care In some cases, older adults need more support than is possible with just home modification, but still do not need assistance on a full-time basis. For them, one pos- sible option may be adult day care. Adult day care is designed to provide support, companionship, and certain services during the day. This situation arises most often when the primary caregiver is employed or has other obligations and is unavailable during the day.
The primary goal of adult day care is to delay place- ment into a more formal care setting. It achieves this goal by providing alternative care that enhances the client’s self-esteem and encourages socialization. Three gen- eral types of adult day care are available (National Adult Day Services Association, 2012). The first provides only social activities, meals, and recreation, with minimal health services. The second type is adult day health care that provides more intensive health and therapy inter- vention and social services for people with more serious medical problems or who require intensive nursing care for a specific medical condition. The third provides spe- cialized care to particular populations, such as people with dementia or developmental disabilities.
Adult day care centers can be independent or sponsored by a profit ( 22 % ) or nonprofit ( 78 % ) orga- nizations. They may provide transportation to and from the center. Depending on the services received, Medicaid or other insurance may cover some of the
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138 CHAPTER 5
expenses (Medicare does not). Because some states do not license adult day care centers, careful screening of a particular center is advised.
About 35 % of adult day care clients live with an adult child and 20 % with a spouse or partner. The average age of clients is over 70 , and about two-thirds are women (National Adult Day Services Associa- tion, 2012). Family members choosing adult day care (and can afford it) typically do so because they need occasional assistance with caregiving, have safety con- cerns about the care recipient when the caregiver is not around, take increasing amounts of time off from work for caregiving, are experiencing problems in their
relationship with the care recipient, or the care recipi- ent could benefit from more contact with other older adults (MetLife, 2010).
For people with cognitive impairment, changes in routine can result in confusion or disruptive behav- ior. It is especially important for them, as it is for all older adults who may become adult day care clients, to inform them of this choice. A good strategy is to engage in a few trials to find out how well the person acclimates to the different surroundings and activities.
Research demonstrates adult day care is a viable and important option for caregivers. Caregivers are interested in programs that meet the needs of their
Kitchen: Would contain
a small refrigerator, a
microwave and a
combined washer-dryer,
along with such features
as a timed medication
dispenser.
Materials: The floor
is a single, molded piece
of a concrete-like composite
that includes a shower
drain. Metal studs attach
to the floor. The exterior
is vinyl siding.
Bedroom: The cottage can house
only one person legally, but an
additional bed can accommodate
a visiting caregiver.
Dimension Eight-foot
interior
ceilings.
12 ft
24 ft
Bathroom: Many “smart”
devices can be installed,
including a toilet that
measures a person’s
weight, temperature
and urine content.
Figure 5.3 An example of an auxiliary dwelling unit. © 2015 Cengage Learning
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 139
loved ones and are generally satisfied with the ser- vices provided (Madeo, Feld, & Spencer, 2008). Fam- ily members clearly seek what is best for their loved one in searching for and helping make the transition to adult day care centers (Bull & McShane, 2008; Musolf, 2012). However, as a study in Australia demonstrated, family caregivers can be overwhelmed by the amount of information and confused by the process of placing their family member (Robinson et al., 2012).
Evidence is clear that compared with keeping rela- tives with cognitive impairment at home, good adult day care programs can reduce problematic behaviors and lower the need for psychotropic medication in clients, and result in lower reports of caregiving bur- den among caregivers (Mosello et al., 2008; MetLife, 2010). However, a key factor in the success of day care programs is having culturally appropriate programs in interventions, as demonstrated in studies of Korean (Park, 2008) and Chinese (Yeung, Wong, & Mok, 2011) clients who benefitted most when programs took their cultural background into account.
Congregate Housing Congregate housing includes a range of living options from those providing only housing to those provid- ing some level of medical services (Howe, Jones, & Tilse, in press). The most common form is an apart- ment complex of older adults that provides a level of support such as shared meals. Congregate housing is often the least expensive form of supported living for older adults, because the cost is typically subsidized by various government agencies and nonprofit orga- nizations. Because of its affordability, it is an espe- cially important option for low-income older adults who need support to remain out of a nursing home. However, there is a shortage of congregate housing in the United States.
Traditional congregate housing differs from assisted living in terms of the level of services pro- vided. Although many traditional congregate hous- ing complexes do not include individual kitchens and provide shared meals, the level of medical assistance, for example, is lower than in assisted living. Congre- gate housing facilities do not provide 24 -hour medical services on site. Currently, newer congregate housing complexes are including higher levels of other service, so the distinction with assisted living is being blurred.
The service coordination provided in congre- gate living accomplishes several things: interface with housing officials, individual service plans for residents, coordination of shared activities (e.g., cleaning com- mon spaces), and mediation of resident conflicts. Most congregate housing complexes require residents be capable of independent living and not require contin- ual medical care, be medically stable, know where they are and oriented to time (e.g., know today’s date and other key time-related information), show no evidence of disruptive behavior, be able to make independent decisions, and be able to follow any specific service plan developed for them. If at some point a resident no longer meets one of the criteria, he or she is usually required to move out.
The decision to move into congregate housing is usually done in conjunction with one’s family, and is typically a response to a significant decline in func- tioning or other health-related problem (Sergeant & Ekerdt, 2008). The best decisions about where one should live in late life are those that lead to outcomes that are congruent to the person’s needs and goals (Golant, 2011); congregate living can work for those seeking specific types of social engagement.
Assisted Living Given that maintaining a sense of place, a home, is important to older adults, it should not come as a sur- prise that they prefer living options that foster that desire. That is how the option of assisted living came into being (Scheidt & Schwarz, 2010). Assisted living facilities are housing options for older adults that pro- vide a supportive living arrangement for people needing assistance with personal care (such as bathing or taking medications) but who are not so impaired physically or cognitively that they need 24 -hour care.
An ideal assisted living situation has three essential attributes (Scheidt & Schwarz, 2010). First, the physi- cal environment where a person lives is designed to be as much like a single-family house as possible. That way, the setting has a residential appearance, a small scale, and personal privacy that includes at a minimum a private room and a full bath that is not shared with other residents unless the resident explicitly wishes. The public spaces in the facility are designed to pro- vide indoor and outdoor access, which enhances a resi- dent’s autonomy and independence.
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140 CHAPTER 5
Second, the philosophy of care at an ideal assisted living facility emphasizes personal control, choice, dig- nity, and autonomy, and promotes a preferred lifestyle residents and their families consider to be a “normal,” good quality of life. This philosophy is implemented by understanding residents’ personal preferences and priorities, and allowing residents to exert control over their lives, schedules, and private dwellings.
Third, ideal assisted living facilities should meet res- idents’ routine services and special needs. It is important to keep in mind that assisted living facilities foster resi- dents’ autonomy, so the levels of support provided are not meant to deal with high level, intensive nursing or other complex needs (Thomas, Guihan, & Mambourg, 2011). Supports tend to include transportation, social- ization, and daily checks to establish how residents are doing that day. For some families, a choice may need to be made between the greater autonomy in assisted liv- ing and greater support in long-term care facilities.
Despite the fact assisted living facilities have existed for more than 20 years, there are serious gaps in ser- vice and in regulations (Scheidt & Schwarz, 2010). For example, no national consensus or federal guidelines exist to govern the characteristics of the people who can and should be served in these facilities, the services provided, or minimum staffing standards. The different combinations of housing and service arrangements that today are called assisted living “make simple generaliza- tions about either their physical settings or their care environments particularly challenging—and inevitably contribute to consumer confusion” (Golant, 2008, 7 ).
Despite the problems with precisely defining assisted living facilities, the number of them contin- ues to grow. In the United States, there are over 30 , 000 assisted living facilities with over 1 million residents, and there is continued expectation for growth over the next few decades as the baby boom generation ages. One important reason for this growth is that assisted living offers a more cost-effective approach than long- term care facilities for those older adults who cannot live independently but do not need the level of nursing care provided in a long-term care facilities.
Residents in assisted living facilities are in inde- pendent apartments or similar units. The services they provide vary, but usually include monitoring and man- agement of health care, assistance with activities of daily living, housekeeping and laundry, reminders or
assistance with medication, recreation and entertain- ment activities, transportation, and security (Elder- care.gov, 2012). Before choosing an assisted living facility, you should check several things:
Think ahead. What will the resident’s future needs be and how will the facility meet those needs?
Is the facility close to family and friends? Are there any shopping centers or other businesses nearby (within walking distance)?
Do admission and retention policies exclude peo- ple with severe cognitive impairments or severe physical disabilities?
Does the facility provide a written statement of the philosophy of care?
Visit each facility more than once, sometimes unannounced.
Visit at meal times, sample the food, and observe the quality of mealtime and the service.
Observe interactions among residents and staff. Check to see if the facility offers social, recre-
ational, and spiritual activities. Talk to residents. Learn what types of training staff receive and how
frequently they receive training. Review state licensing reports.
Residents generally pay the costs of assisted living facilities, which ranged between $ 25 , 000 and $ 50 , 000 per year in 2012 (Eldercare.gov, 2012). Medicare does not pay for either living costs or any of the services pro- vided. In some cases, Medicaid may pay for services depending on the situation. Given that assisted living is usually less expensive than nursing homes, the lack of broad financial support for these programs means that the cost of care is not as low as it could be.
Research on assisted living increased as more assisted living options appeared. Residents’ well-being is related to whether the decision to live there was under their control and to the quality of relationships formed with co-residents (Street & Burge, 2012). A review of housing needs for older adults in Western Europe revealed a serious need for a range of alternatives, especially in assisted living (Stula, 2012). Because of an anticipated increase in number of older adults who will
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 141
need assistance and an increase in the range of func- tional impairments that older adults will experience, living facilities will need to have more flexible designs.
One of the main future challenges will be the blur- ring of congregate (independent) living, assisted liv- ing, and long-term care facilities into hybrids of these arrangements (Scheidt & Schwarz, 2010). The hope is more stringent regulations will follow the blend- ing of these forms of housing, and services will not destroy the special characteristics of assisted living. Another challenge, both now and in the future, is the cost of assisted living, which is already out of the reach of many elderly Americans. Finally, researchers point to the need for updating our views of residential options for older adults (Golant, 2012). Because the future role of the government in providing funds for affordable shelter and care will continue to be limited, individuals and families will assume the largest financial burden of providing long-term care funds for their loved ones. Having access to the resources that this requires will be a major issue.
5.3 Living in Nursing Homes LEARNING OBJECTIVES
What are the major types of nursing homes? Who is most likely to live in nursing homes? What are the key characteristics of nursing
homes? What are special care units? How can a nursing home be a home? How should people communicate with nursing
home residents? How is decision-making capacity assessed? What are some new directions for nursing homes?
T he last place Maria thought she would end up was a bed in one of the local nursing homes. “That’s a place
where old people go to die,” she used to say. “It’s not gonna be for me.” But here she is. Maria, 84 and living alone, fell and broke her hip. She needs to stay for a few weeks while she recovers. She hates the food; “tasteless goo,” she calls it. Her roommate, Arnetta, calls the place a “jail.” Arnetta, 79 and essentially blind, has Alzheimer’s disease.
Maria and Arnetta may be the kind of people you think of when you conjure up images of nursing homes. To be sure, you will probably find some people like them there. But for each Maria or Arnetta, there are many more that come to terms with their situa- tion and struggle to make sense of their lives. Nursing homes are indeed places where people who have seri- ous health problems go, and for many it is their final address. Yet if you visit a nursing home, you will find many inspiring people with interesting stories to tell.
Misconceptions about nursing homes are common. Contrary to what some people believe, only about 5 % of older adults live in nursing homes on any given day. As you can see in Figure 5.4 , the percentage of older adults enrolled in Medicare who live in a long-term care facil- ity at any given point in time increases from 2 % in those aged 65 – 74 to about 14 % of adults over age 85 (AgingStats. gov, 2012); however, over their lifetime, over 50 % of older women and about 30 % of older men will spend at least some time in a long-term care facility (Georgia Health Care Association, 2012). The gender difference is because older women take care of their husbands at home, but in turn need to relocate to a long-term care facility for their own care because their husbands are, on average, deceased.
Long-term care settings are different environ- ments from those we have considered so far. The resi- dents of such facilities differ in many respects from their community-dwelling counterparts. Likewise, the environment itself is dissimilar from neighborhood and community contexts. But because many aspects of the environment in these facilities are controlled, they offer a unique opportunity to examine person– environment interactions in more detail.
In this section we examine types of long-term care settings, the typical resident, the psychosocial envi- ronment, and residents’ ability to make decisions for themselves.
Types of Nursing Homes Nursing homes house the largest number of older resi- dents of long-term care facilities. They are governed by
Adult Development in Action As a gerontological social worker, what key factors would you consider when making recommendations about the best housing/living options for your older adult clients?
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142 CHAPTER 5
state and federal regulations that establish minimum standards of care. Two levels of care in nursing homes are defined in U.S. federal regulations (Allen, 2011). Skilled nursing care consists of 24 -hour care includ- ing skilled medical and other health services, usually provided by nurses. Intermediate care is also 24 -hour care including nursing supervision, but at a less intense level. In actual practice, the major differences between the two are the types and numbers of health care
workers on the staff. Perhaps for this reason, the dis- tinction between skilled and intermediate care often is blurred.
The cost of nursing home care is high. With the aging of the baby-boom generation, how this cost will be met is an issue confronting millions of families. As noted in the Current Controversies feature, funding for nursing homes will be an increasingly important political issue in the coming decades.
Figure 5.4 Percentage of Medicare enrollees age 65 and over in selected residential settings by age group, 2009. Source: Centers for Medicare and Medicaid Services, Medicare Current Beneficiary Survey.
100
Percent
80
60
40
20
0 65 and over 75–8465–74 85 and over
Community housing with services
Traditional community
Long-term care facilities
93
3 4
97
1 2
93
3 4
78
8
14
CURRENT CONTROVERSIES: FINANCING LONG-TERM CARE The current system of financing long-term care in the United States is in serious trouble. The average cost of a private room is about $ 90 , 500 per year at the begin- ning of 2013 (MetLife, 2012) and is by far the leading catastrophic health care expense. The Centers for Medi- care and Medicaid Services (2012) estimates that by 2021 national expenditures for nursing home care will rise about $ 100 billion per year to $ 255 billion. Contrary to popular belief, Medicare does not cover nursing home
care but does have limited nursing home and home care benefits for people who need skilled nursing services and who meet other criteria. Private insurance plans pay less than 10 % of the costs nationally. About 25 % of the expense is paid directly by nursing home residents. When residents become impoverished (a definition that varies widely from state to state), they become dependent on Medicaid, that pays the bulk of the total. (In 2010, the total Medicaid expenditures for skilled nursing home care were roughly $ 45.1 billion, or 31.5 % of the total national expenditure on nursing home care.) Given these expenses and the lack of insurance coverage, how will we be able to finance the long-term health care system?
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 143
Who Is Likely to Live in Nursing Homes? Who is the typical resident of a nursing home? She is over age 85 , European American, recently admitted to a hospital, living in a retirement home rather than being a homeowner, is cognitively impaired, has problems with IADLs, is probably widowed or divorced, and has no siblings or children living nearby. Maria and Arnetta, whom we met in the vignette, reflect these character- istics. However, this profile is changing rapidly (Feng, Fennell, Tyler, Clark, & Mor, 2011). Latino Ameri- can and Asian residents increased roughly 55 percent each between 1999 and 2008, and African American residents increased nearly 11 percent. Meanwhile, European American residents declined 10 percent.
What are the health issues and functional impair- ments of typical nursing home residents? For the most part, the average nursing home resident has signifi- cant mental and physical problems. The main reason
for placing almost 80 % of nursing home residents is significant health problems (AgingStats.gov, 2012). Estimates show nearly 80 % of residents have mobility problems, and more than one third have mobility, eat- ing, and incontinence issues. In addition, the rates of mental health and cognitive impairment problems are high, with between 30 and 50 % of residents showing signs of clinical depression.
As you may surmise from the high level of impair- ment among nursing home residents, frail older peo- ple and their relatives do not see nursing homes as an option until other avenues have been explored. This may account for the numbers of truly impaired people who live in nursing homes; the kinds and number of problems make life outside the nursing home difficult for them and their families and beyond the level of assis- tance provided by assisted living facilities. For these rea- sons, the decision to place a family member in a nursing
Several options have been proposed, taking the Affordable Health Care Act into account (Pettinato, 2013). Four main strategies are possible:
A strategy that promotes private long-term care insurance and keeps public financing as a safety net. This approach spreads the financial risk with- out expanding the demands on federal or state budgets and taxpayers to pay fully for long-term care. Still, a public safety net would be essential as a last resort.
A strategy to expand the public safety net for people with low to moderate incomes, with people from higher-income brackets expected to provide for themselves through private financ- ing. This approach is a needs-tested model that targets the people with the greatest need and the fewest resources for government assistance.
A strategy to establish public catastrophic long- term care insurance and support complementary private insurance to fill the gap along with the public safety net. This approach spreads the risk and the burden on a greater number of people, reducing the cost of private insurance, but still pricing it beyond the means of many older adults.
A strategy to establish universal public long-term care insurance supplemented with private financ- ing and a public safety net. This approach spreads the burden over the greatest number of people,
thereby addressing the problem of affordability of private insurance.
Despite the wide range of options, many of them still place the burden on individuals to devise ways of financing their own care. Given the cost, and the fact that millions of Americans do not have access to health insurance, large subsidies from the government will still be needed for long-term care regardless of what the private sector does.
Given that government subsidies for long-term care will be needed for the foreseeable future, the ques- tion becomes how to finance them. Under the current Medicaid system, older adults are not protected from becoming impoverished, and in essence are required to have few assets in order to qualify. With the aging of the baby-boom generation, many more people will spend their assets, causing Medicaid costs to skyrocket. If we want to continue the program in its current form, additional revenues will be needed, either in the form of taxes or dramatic spending reductions in other areas of public budgets.
The questions facing us are whether we want to continue forcing older adults to become totally impover- ished when they need long-term care, the government to continue subsidy programs, encourage those who can afford it to buy long-term care insurance, and if we are willing to pay higher taxes for better coverage. How we answer these questions will have a profound impact on the status of long-term care over the next few decades.
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144 CHAPTER 5
home is a difficult one (Beaulieu, 2012; Caron, Ducha- rme, & Griffith, 2006), even when the family member in question has serious cognitive impairment (Klug, Volkov, Muus, & Halaas, 2012). Placement decisions are often made quickly in reaction to a crisis, such as a person’s impending discharge from a hospital or other health emergency. The decision tends to be made by partners or adult children, a finding generalized across ethnic groups such as European Americans, Mexican Americans, and Koreans, especially when there is evi- dence of cognitive impairment (Almendarez, 2008; Klug et al., 2012; Kwon & Tae, in press).
Characteristics of Nursing Homes Nursing homes vary a great deal in the amount and quality of care they provide. One useful way of evaluating them is by applying the competence– environmental press model. When applied to nursing homes, the goal is to find the optimal level of envi- ronmental support for people who have relatively low levels of competence.
Selecting a nursing home should be done carefully. The Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services pro- vides a detailed Nursing Home Quality Initiative web- site that is a guide for choosing a nursing home based on several key quality factors. Among the most impor- tant things to consider are:
Quality of life for residents (e.g., whether residents are well groomed, the food is tasty, and rooms contain comfortable furniture);
Quality of care (whether staff respond quickly to calls, whether staff and family are involved in care decisions);
Safety (whether there are enough staff, whether hallways are free of clutter); and
Other issues (whether there are outdoor areas for residents to use).
These aspects of nursing homes reflect those dimen- sions considered by states in their inspections and licensing process.
Individuals and families should also keep several other things in mind:
Skilled nursing care is usually available only for a short time following hospitalization, whereas
custodial care may be an option for a much longer period. If a facility offers both types, it may or may not be possible to shift level of care without relo- cating to another room.
Nursing homes that only take Medicaid residents may offer longer term but less intensive care levels. Nursing homes that do not accept Medicaid may force the resident to leave when Medicare or pri- vate funds run out.
Ensure the facility and its administrator are fully licensed, and a full array of staff training is avail- able on such topics as recognizing abuse and neglect, how to deal with difficult residents, and how to investigate and report your complaints.
Ensure the resident’s care plan is put together by a team of professionals, and residents have choices, can exert some control over their routines and care, and have appropriate assistance with ADLs and IADLs.
Ask questions about staff educational levels (including continuing education) and turnover. Based on the various theories of person– environment
interaction discussed earlier in this chapter, the best nursing homes use what researchers recommend—a “person-centered care” approach to nursing home poli- cies (Morgan & Yoder, 2012), especially when working with people who have cognitive impairment (Lawlor & York, 2007). Although there is not yet complete con- sensus about the underlying characteristics of person- centered care (Morgan & Yoder, 2012), in general this approach is based on promoting residents’ well-being through increasing their perceived level of personal con- trol and treating them with respect. An example of this approach includes such things as residents getting to decorate their own rooms, choosing what they want to eat from a buffet, and deciding whether they want to take a shower or a bath. Person-centered planning focuses on the individual, and does not use a one-size- fits-all approach. Most important, this approach involves a team who knows and cares about the individual who work together with the person to create the best sup- portive environment possible.
Such policies are grounded in classic research showing that residents who have higher perceived personal control show significant improvement in well-being and activity level, and actually live lon- ger (Langer & Rodin, 1976; Rodin & Langer, 1977).
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 145
Nursing homes using the person-centered planning approach also note major decreases in the need for certain medications (e.g., sleep and anti-anxiety drugs) and soft restraints, as well as substantial declines in the number of residents who are incontinent (Reese, 2001). Feelings of self-efficacy are crucial to doing well and adjusting to life in a long-term care facility (Brand- burg, Symes, Mastel-Smith, Hersch, & Walsh, in press).
Although the person-centered care approach has been around for years, many nursing homes still rely on a traditional approach of rules, routines, and requirements (Robinson & Gallagher, 2008). Perhaps the best way to begin changing the culture from one where residents are expected to be passive to one that includes them in their own care is to focus on activi- ties related to dining. Choosing what one eats, being able to socialize with one’s friends, and interacting with staff while enjoying a meal is one way to create the level of personal involvement and trust necessary to imple- ment a person-centered approach.
Today, person-centered care is considered a best practice in nursing homes (Dellefield, 2008; Toles & Anderson, 2011). Including nursing home residents in the planning of their own care represents a major shift in culture, and is an example of the application of research to practice.
Special Care Units Most residents of nursing homes have cognitive impairment, and the majority of those individuals have dementia. Providing a supportive environment for people with moderate to severe dementia requires certain specialized design and intervention features. This need has resulted in the development of special care units in many nursing homes.
Well-designed special care units for people with dementia provide a supportive and therapeutic set of programs that help the person function at the highest level possible. Optimally, staff working in special care units receive specific training to work with persons with dementia. The best units have physical design ele- ments that take functional limitations into account; for example, the hallways of some facilities are designed so if residents wander, they merely follow the interior halls or exterior path in a circle so they do not leave the building or the complex, and the decorating is done in a way to minimize confusion. Most facilities
have residents with cognitive impairment wear wrist or ankle bands that trigger alarms if they wander beyond a certain point or exit the facility, another safe way to provide opportunities for residents to move about freely but safely. The best facilities also permit residents to bring a few personal items as reminders of their past in order to provide a more homelike envi- ronment. They also provide a private dining area in a family-like setting in order to minimize possible nega- tive interactions between residents with dementia and residents without cognitive impairment.
Selecting the right special care unit for a person with dementia must be done carefully by the fam- ily with proper input from health care professionals (Gillick, 2012; Paris, 2008). As noted in the compe- tence–environmental press model, as competence declines the environment must provide more support in order for behavior to be optimized. So the special care unit must have the right level of environmental support at the placement, as well as the availability of additional levels of support when the person’s compe- tence level continues to decline. Memory aids should be built into the unit, such as color-coded halls. Staffing levels and training are key as is the range of interven- tion programs and activities available. Such programs should be research based, such as those based on the Montessori techniques discussed in Chapter 10 .
The research-based staff training required at the best special care units includes several aspects of car- ing for older adults with moderate to severe cognitive impairment:
Appropriate and effective communication tech- niques (as discussed later in this section)
Behavioral management techniques to address aggressive or agitated behavior (a common symp- tom in dementia)
Appropriate techniques for assisting with personal health and hygiene that protect residents’ dignity
Appropriate methods for dealing with incontinence Appropriate techniques for handling sexuality in
persons with dementia Effective techniques for controlling wandering (in
addition to physical design aspects of the facility) Appropriate ways of supervising or assisting with
eating
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146 CHAPTER 5
Appropriate techniques and interventions to address memory failure and disorientation
Appropriate techniques for assisting with mobility (e.g., walking, using a wheelchair)
Training in these areas will not guarantee high-quality care, but it increases the likelihood of it.
Research indicates that upon admission, residents of special care units are younger, more behaviorally impaired, and less likely to be minority than general nursing home residents when both exist in the same facility (e.g., Gruneir et al., 2008a; Sengupta, Decker, Harris-Kojetin, & Jones, 2012). Residents of special care units tend to have lower hospitalization rates, were less likely to have serious other health issues (e.g., be tube fed), and have family members who were satisfied with the quality of care than residents of non-special care units (Cadigan, Grabowski, Givens, & Mitchell, 2012). The increased quality of care residents of spe- cial care units receive is more the result of a difference in philosophy of care between nursing homes with and without special care units than it is due to the special care unit itself (Cadigan et al., 2012; Gruneir et al., 2008b). Given the use of physical restraints is associated with higher morbidity (Reid, 2008), it may be nursing homes that include special care units also have differ- ent approaches for dealing with problem behaviors that help avoid the use of or need for physical restraints.
Can a Nursing Home Be a Home? One key aspect of nursing homes has been largely overlooked: To what extent do residents consider a nursing home to be home? This gets to the heart of what makes people feel the place where they live is
more than just a dwelling. On the surface, it appears nursing homes are full of barriers to this feeling. After all, they may have regulations about the amount of furnishings and other personal effects residents may bring, and residents are in an environment with plenty of structural reminders that it is not a house in suburbia. Not having their own refrigerator, for exam- ple, means they can no longer invite friends over for a home-cooked meal (Shield, 1988).
Can nursing home residents move beyond these barriers and reminders and achieve a sense of home? The answer is yes, but with some important qualifica- tions. In a groundbreaking series of studies, Groger (1995, 2002) proposed a nursing home can indeed be perceived as a home. She interviewed older African American adults, some who lived in nursing homes and others who were home care clients, along with a sample of the nursing home residents’ caregivers. Groger’s analyses of her interviews revealed that nurs- ing home residents can feel at home. The circumstances fostering this feeling include having the time to think about and participate in the placement decision, even if only minimally; having prior knowledge and posi- tive experience with a specific facility; defining home predominantly in terms of family and social relation- ships rather than in terms of place, objects, or total autonomy; and being able to establish a kind of conti- nuity between home and nursing home either through activities or similarities in living arrangements.
Groger (2002) points out that residents pull from their repertoire of coping strategies to help them come to terms with living in a nursing home. Groger (1995) also reports that getting nursing home residents to reminisce about home actually facilitates adjustment. Some residents concluded only after long and detailed reflection on their prior home that the nursing home was now home. In addition, it may be easier for nurs- ing home residents to feel at home on some days than others and from one situation to another, depending on the events or stimuli at the time.
Helping nursing home residents feel at home is an important issue that must be explored in more detail. Perhaps having people think about what con- stitutes a home, before and after placement, may make the transition from community to the facility easier to face. For those needing the care provided in a nursing home, anything done to ease the transition is a major
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 147
benefit. Assessing the degree to which residents feel at home is possible (Molony, McDonald, & Palmisano- Mills, 2007), and can be used to document functional changes after placement into a facility (Molony, Evans, Jeon, Rabig, & Straka, 2011).
At a general level, nursing home residents’ satis- faction relates to several key variables: facility, staff, and resident factors, as shown in Figure 5.5 (Chou et al., 2003). Research indicates that staff satisfaction plays a crucial role in nursing home residents’ satisfac- tion. In contrast, providing more care does not (Chou et al., 2003). In addition, when residents have a voice in determining the quality of care, irrespective of their functional abilities, their quality of life improves (Moyle & O’Dwyer, 2012). As we will see next, how people communicate with residents is also key.
Communicating with Residents Have you ever been to a nursing home? If so, one of the things you may have found difficult is talking with the residents, especially when interacting with residents who are cognitively impaired. Unfortunately, this uneasiness often results in people relying on ste- reotypes of older adults in general and nursing home residents in particular in speaking to them and results in inappropriate communication styles.
The communication style most people adopt is one in which younger adults over accommodate their speech based on their stereotyped expectations of dependence and incompetence. This style is described as a general “communication predicament” of older adults (Ryan
et al., 1986). Such speech conveys a sense of declin- ing abilities, loss of control, and helplessness, which, if continued, may cause older adults to lose self-esteem and withdraw from social interactions. As time goes on, older adults who are talked to in this way may even begin behaving in ways that reinforce the stereotypes.
Inappropriate speech to older adults that is based on stereotypes of incompetence and dependence is called patronizing speech. Patronizing speech is slower speech marked by exaggerated intonation, higher pitch, increased volume, repetitions, tag and closed- end questions, and simplification of vocabulary and grammar. Speaking in this way can be conceptualized as “secondary baby talk,” which is baby talk inappro- priately used with adults (Mohlman, Sirota, Papp, Sta- ples, King, & Gorenstein, 2012). Secondary baby talk, also called infantilization or elderspeak, also involves the unwarranted use of a person’s first name, terms of endearment, simplified expressions, short imperatives, an assumption that the recipient has no memory, and cajoling as a way to demand compliance .
In a classic study, Whitbourne and colleagues (1995) established that infantilizing speech is viewed extremely negatively by some older adults. They found community-dwelling older adults rated infantiliz- ing speech especially negatively and were particularly resentful of its intonation aspects as indicative of a lack of respect. Nursing home residents were less harsh in their judgments, giving support to the idea that being exposed to infantilizing speech lowers one’s awareness of its demeaning qualities. Whitbourne and colleagues
RESIDENT SATISFACTION
Room Home Social interaction Meals service Staff care Resident involvement
STAFF FACTORS Staff satisfaction Professional development Care hours/staffing level Work experience
RESIDENT FACTORS Dependency Age Sex
FACILITY FACTORS Size Location Age Ownership
Figure 5.5 Major factors influencing resident satisfaction in nursing homes. Source: Chou, S-C., Boldy, D. P., & Lee, A. H. (2003). Factors influencing residents’ satisfaction in residential aged care. The Gerontologist 43, 459–472, Copyright © Reprinted with permission from the Gerontological Society of America.
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148 CHAPTER 5
also found no evidence that infantilizing speech is high in nurturance, as some previous authors had suggested.
Residents with dementia tend to be more resis- tive to care when they are the targets of elderspeak (Williams et al., 2008). In younger adults, use of patronizing speech appears to be related to the amount of interaction they have had with unrelated older adults (i.e., older adults who are not their relatives), with more experience being related to lower use of patron- izing speech (Hehman, Corpuz, & Bugental, 2012).
It turns out there may be different types of elder- speak, with different effects on the targets of the com- munications. In a study described in more detail in the How Do We Know? feature, Chee (2011) examined elderspeak in an eldercare facility in Singapore. Choi discovered there may be at least two types of elderspeak, what she terms “right” and “wrong.” She also demon- strated elderspeak is a common approach used in a vari- ety of settings, but that it is used toward older women most often.
HOW DO WE KNOW?: IDENTIFYING DIFFERENT TYPES OF ELDERSPEAK IN SINGAPORE Who were the investigators, and what was the aim of the study? Older adults who attend day services pro- grams face many difficulties with the way people talk to (or about) them. The concept of patronizing speech, discussed in the text, captures the essence of the prob- lem. Felicia Yi Tian Chee (2011) decided to establish the different kinds of patronizing speech used in such settings.
How did the investigator measure the topic of interest? Chee initially spent significant amounts of time at the adult day care center in Singapore to establish rapport with the clients. Data were gathered through observations and note taking during normal interactions between staff and clients. A coding system was developed to reflect different aspects of speech toward the older adult clients: (a) limited vocabu- lary, mirroring the limited vocabulary and sentence structure used when children are learning to speak; (b) infantilizing and over-parenting, when the staff member assumes the role of “parent” and treats the client as if he/she were the “child,” an approach used most in conversations about toileting, displays of ver- bal affection, and reprimanding; and (c) repetition, which includes expansion, semantic elaboration, and comprehension checks.
Who were the participants in the study? Partici- pants were 30 older adult clients ( 8 males, 22 females) with a variety of health conditions. Most of the clients were ethnic Chinese, but there were 3 ethnic Indi- ans. Older adults’ first languages varied, with most speaking Mandarin Chinese. For purposes of data analyses, clients were grouped into three clusters: those who were healthy and ambulatory, those who
were healthy and wheelchair-bound, and those with dementia.
What was the design of the study? The design was naturalistic observation. Chee observed verbal commu- nication interactions without participating herself.
Were there ethical concerns with the study? All participants were volunteers.
What were the results? Chee observed greater use of elderspeak with those clients who had greater physical or cognitive dependency on the caregiving staff. Thus, clients in wheelchairs and those with dementia were the targets of elder- speak more often than healthy clients. Although clients with dementia received all three types of elderspeak, they received the least reprimanding or domineering speech, perhaps because the staff perceived them as more in need of care. Clients in wheelchairs received nearly as much elderspeak as those with dementia. Female clients received more elderspeak than male clients.
More elderspeak occurred in situations in which clients were dependent on staff to help them perform some function, such as toileting or feeding. Situations in which clients were being encouraged to perform a task were also common ones in which elderspeak was used.
Clients did not appear to react strongly to elderspeak. Chee surmises that they either resigned themselves to it or chose not to respond.
What did the investigators conclude? Elderspeak occurs in a wide variety of interactions with clients in day services centers, but is related to level of physical or cognitive ability.
Chee concluded elderspeak aimed at comprehen- sion checking and encouragement, when no other elements of elderspeak are present, may enhance cli- ents’ performance. In contrast, other forms of elder- speak tended to result in poorer performance of the task at hand.
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 149
So how should people talk to older adults, espe- cially those needing services or living in long-term care facilities? Ryan and her colleagues (1995) initially proposed the communication enhancement model as a framework for appropriate exchange. This model is based on a health promotion model that seeks oppor- tunities for health care providers to optimize outcomes for older adults through more appropriate and effec- tive communication. As you can see from Figure 5.6 , this model emphasizes communication with older adults must be based on recognizing individualized cues, modifying communication to suit individual needs and situations, appropriately assessing health and social problems, and empowering both older adults and health care providers.
Combining the communication enhancement model with the person-centered care model discussed
earlier provides a way for paraprofessional staff in long-term care facilities to communicate more effectively with residents, including those living on dementia spe- cial care units (Passalacqua & Harwood, 2012). Such strategies are important if the culture in long-term care facilities is to change.
Ryan and colleagues’ model and research can be readily applied to interactions with older adults from different ethnic groups and with older adults who have cognitive impairments. An analysis of intergenera- tional communication comparing Western and Eastern cultures showed complex cultural variability, including the occurrence of less positive perceptions of conversa- tions in some cases from respondents in Korea, Japan, China, Hong Kong, and the Philippines than in some Western countries (Williams et al., 1997). But cultural norms also influence communication. As the persons
Figure 5.6 The communication enhancement model. Note that this model is dynamic in that there are opportunities to modify communication interactions and to have the outcomes of one interaction serve as input for another. Source: E. B. Ryan, S. D. Meredith, M. J. MacLean, and J. B. Orange, 1995. Changing the way we talk with elders: Promoting health using the Communication Enhancement Model. International Journal of Aging and Human Development 41, 89–107. Reproduced by permission.
Maximized communication
skills and opportunities
Optimized health, well-being,
and competence of client
Empowerment of client and provider
Increased effectiveness
and satisfaction of provider
Individual assessment
for multifocused interventions
Recognition of clues
on an individual basis
Modified communication
to accommodate individual need
Encounter with older person
Multiple environmental influences
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150 CHAPTER 5
they were talking to grew older, younger adult Thais and Japanese increased their communicative respect and deference (Ota, McCann, & Honeycutt, 2012).
In general, an approach to communication based on the communication enhancement model promotes mental, social, and physical well-being among older adults and counters the fostering of dependence that follows from the traditional medical model discussed earlier. When patronizing speech occurs in nurs- ing homes, active steps should be taken to eliminate it (Dobbs et al., 2008). Most important, this research reminds us we must speak to all older adults in a way that conveys the respect they deserve.
So what should you do as a visitor? The first time most people visit a nursing home, they are ill-prepared to talk to family members who are frail, have trouble remembering, and cannot get around easily. The hard- est part is trying to figure out what to say in order to avoid patronizing speech. However, visiting residents of nursing homes is a way to maintain social contacts and provide a meaningful activity. Even if the person you are visiting is frail, has a sensory impairment, or some other type of disability, visits can be uplifting. As noted earlier in the chapter, high-quality social contacts help older adults maintain their life satisfaction. Here are several suggestions for making visits more pleas- ant (Papalia & Olds, 1995; adapted from Davis, 1985), along with guidance from the Gerontological Society of America (2012):
Face older adults when you speak to them, with your lips at the same level as theirs.
Ask open-ended questions and genuinely listen. Concentrate on the older adult’s expertise and
wisdom, as discussed in Chapter 14 , by asking for advice on a life problem he or she knows a lot about, such as dealing with friends, cooking, or crafts.
Ask questions about an older adult’s living situa- tion and social contacts.
Allow the older person to exert control over the visit: where to go (even inside the facility), what to wear, what to eat (if choices are possible).
Listen attentively, even if the older person is repet- itive. Avoid being judgmental, be sympathetic to complaints, and acknowledge feelings.
Talk about things the person likes to remember, such as raising children, military service, growing up, work, courtship, and so on.
Do a joint activity, such as putting a jigsaw puzzle together, arranging a photograph album, or doing arts and crafts.
Record your visit on audiotape or videotape. This is valuable for creating a family history you will be able to keep. The activity may facilitate a life review as well as provide an opportunity for the older person to leave something of value for future generations by describing important personal events and philosophies.
Bring children when you visit, if possible. Grand- children are especially important, because many older adults are happy to include them in conver- sations. Such visits also give children the opportu- nity to see their grandparents and learn about the diversity of older adults.
Stimulate as many senses as possible. Wearing bright clothes, singing songs, reading books, and sharing foods (as long as they have been checked and approved with the staff ) help to keep resi- dents involved with their environment. Above all, though, hold the resident’s hands. There’s nothing like a friendly touch. Always remember your visits may be the only way
the residents have of maintaining social contacts with friends and family. By following these guidelines, you will be able to avoid difficulties and make your visits more pleasurable.
Decision-Making Capacity and Individual Choices
Providing high-quality care for nursing home residents means putting into practice the various competence- enhancing interventions we have discussed relating to personal control and communication. Doing so means residents participate in making decisions about their care. But how can we make sure residents understand what they are being asked to decide, especially when a majority of them have cognitive impairment?
The need to address this question became appar- ent in 1991 with the enactment of the Patient Self- Determination Act (PSDA). This law mandated all
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 151
facilities receiving Medicare and Medicaid funds com- ply with five requirements regarding advance care plan- ning, referred to as advance directives (Emanuel, 2008):
Providing written information to people at the time of their admission about their right to make medical treatment decisions and to formulate advance directives (i.e., decisions about life- sustaining treatments and who can make medical decisions for them if they are incapacitated);
Maintaining written policies and procedures regarding advance directives;
Documenting the completion of advance direc- tives in the person’s medical chart;
Complying with state law regarding the imple- mentation of advance directives; and
Providing staff and community education about advance directives.
The PSDA mandates work well with most people. However, assessing a person’s capacity to make medi- cal decisions is a tremendous challenge for medical ethics (American Geriatrics Society Ethics Commit- tee, 1996; Rich, 2013). In theory, advance directives enable people to choose the type of medical treatment they prefer in advance of a medical crisis. However, numerous studies show the theory does not hold up well in practice: Most people, especially older adults, see such planning as a family process. They engage in informal advance care planning, preferring to allow family members to make decisions for them when the need arises and to give them leeway in interpret- ing advance directives even when they exist (Allen & Shuster, 2002). Thus it is unlikely a person being admitted to a nursing home will have completed a for- mal advance directive.
Because placement in a nursing home is already stressful and likely to occur in the context of a medi- cal crisis, the new resident is unlikely to understand the information presented as mandated by the PSDA. To make matters worse, if new residents are cogni- tively impaired, they may be thought to be unable to act in their own behalf in communicating treatment preferences and end-of-life wishes and understanding the consequences of their choices (Allen et al., 2003), although there still may be ways to assist them in
expressing their preferences (Moriarty, Rutter, Ross, & Holmes, 2012). The degree to which cognitive impair- ment interferes with a person’s ability to decide their treatment raises important ethical questions concern- ing whether physicians can trust any advance directive signed by such individuals after they move to a nursing home (Gillick, 2012; Kapp, 2008).
Assessing a nursing home resident’s ability to make medical treatment decisions can be conceptual- ized as a problem involving the fit between the original intent of the law and the resident’s cognitive capacity (Allen et al., 2003; Smyer & Allen-Burge, 1999). Sev- eral researchers have tackled the problem of how to assess decision-making capacity with varying results. Most important, a careful assessment of the resident’s capacity to understand treatment and intervention options is necessary (Gillick, 2012; Kapp, 2008).
Still, many problems remain. No uniform approach to determining residents’ cognitive competence exists, although progress is being made through the estab- lishment of guidelines (American Bar Association/ American Psychological Association, 2005, 2006, 2008). One barrier to a common approach is that each state sets the criteria needed to demonstrate cognitive competence (which is usually approached from the opposite side—what it takes to establish incompetence). To complicate matters further, research also shows lack of agreement between what nursing home residents want and what their families think they would want, and this also varies with ethnicity (Connolly, Sampson, & Purandare, 2012; Winter & Parks, 2012). Resolving the problem involves using the various approaches we considered for determining person–environment interactions, combined with strong clinical assessment (see Chapter 10 ), in the context of specific treatment goals and maintaining quality of life. Clearly, creating an optimal solution takes an interdisciplinary team of professionals, residents, and family members working together.
One solution may be to assess key members of the family (who serve as proxies in completing the forms) as to their beliefs as well as careful observation of the resident’s capacity by the staff (Allen et al., 2003). Health care staff also need to sit down with family members and talk with them directly about treatment options so better decisions are made (Feltz & Samayoa, in press).
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152 CHAPTER 5
New Directions for Nursing Homes Nursing homes are not static entities. New ways of approaching care continue to be developed. Three interesting new developments are the Eden Alternative, the Green House Project, and the Pioneer Network.
The Eden Alternative. Imagine an approach to car- ing for frail older adults starting from the premise that skilled care environments are habitats for people rather than facilities for the frail. Such an environment has the potential to address issues such as boredom, loneli- ness, and helplessness. The Eden Alternative takes this approach.
Founded by Dr. William and Judy Thomas, the Eden Alternative approaches care from the perspective of protecting the dignity of each person. It is based on the following 10 principles:
1. The three plagues of loneliness, helplessness, and boredom account for the bulk of suffering among our elders.
2. An elder-centered community commits to creating a human habitat where life revolves around close and continuing contact with plants, animals, and chil- dren. It is these relationships that provide the young and old alike with a pathway to a life worth living.
3. Loving companionship is the antidote to loneli- ness. Elders deserve easy access to human and animal companionship.
4. An elder-centered community creates opportunity to give as well as receive care. This is the antidote to helplessness.
5. An elder-centered community imbues daily life with variety and spontaneity by creating an envi- ronment where unexpected and unpredictable interactions and happenings can take place. This is the antidote to boredom.
6. Meaningless activity corrodes the human spirit. The opportunity to do things that we find mean- ingful is essential to human health.
7. Medical treatment should be the servant of genu- ine human caring, never its master.
8. An elder-centered community honors its elders by de-emphasizing top-down bureaucratic authority, seeking instead to place the maximum possible
decision-making authority into the hands of the elders or into the hands of those closest to them.
9. Creating an elder-centered community is a never- ending process. Human growth must never be separated from human life.
10. Wise leadership is the lifeblood of any struggle against the three plagues. For it, there can be no substitute.
Arguably, the Eden Alternative helped launch a culture change in nursing homes that improved residents’ quality of life (Kapp, in press; Rahman & Schnelle, 2008) by blending person-centered care with relational care (care that takes unintended actions into account) (Rockwell, 2012). The main outcomes of this movement are resident-directed care and staff empowerment. Research indicates the cultural changes resulting from the Eden Alterna- tive are associated with less feelings of boredom and helplessness and improved quality of life (Bergman- Evans, 2004; Kapp, in press).
Green House Project. The Green House concept is grounded in the Eden Alternative. It is a radical departure from the concept that skilled nursing care is best provided in large residential facilities. In con- trast, a Green House aims to provide older adults who need skilled nursing care a small, homelike environ- ment that shifts the focus from a large facility to a more homelike setting. Only 6 – 10 residents live there, in a dwelling that blends architecturally with houses in the neighborhood, making it much more homelike (Kapp, in press; Rabig et al., 2006; Zarit & Reamy, in press).
The Green House concept emphasizes the impor- tance of encouraging residents to participate in their care by helping with daily tasks such as cooking and gardening, assisted by specially trained staff ( Johnson & Rhodes, 2007). By emphasizing participation in one’s own care to the extent possible, personal dignity is maintained, and quality of life improved (Kane et al., 2007). As a result, the Green House concept is spread- ing across the United States as a viable alternative to large nursing homes.
The Pioneer Network. The Pioneer Network is also dedicated to changing the way older adults are treated
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 153
in society, particularly in care facilities. The Pioneer Network focuses on changing the culture of aging in America regardless of where older adults live. Like the Eden Alternative, this approach focuses on respect- ing older adults and providing maximally supportive environments for them. Their values are also similar in spirit:
Know each person. Each person can and does make a difference. Relationship is the fundamental building block of
a transformed culture. Respond to spirit, as well as mind and body. Risk taking is a normal part of life. Put the person before the task. All elders are entitled to self-determination wher-
ever they live. Community is the antidote to institutionalization. Do unto others as you would have them do unto
you. Promote the growth and development of all. Shape and use the potential of the environment in
all its aspects: physical, organizational, psychoso- cial, and spiritual.
Practice self-examination, searching for new creativity and opportunities for doing better.
Recognize culture change and transformation are not destinations but a journey, always a work in progress. The Pioneer Network, as part of the larger cultural
change in caring for older adults, advocates a major emphasis on making nursing homes more like a home, and works in cooperation with the Centers for Medi- care and Medicaid Services to work for revisions in nursing home regulations (Schoeneman, 2008). This work is aimed at creating a new culture of aging.
What the Eden Alternative, the Green House con- cept, and the Pioneer Network have in common is a commitment to viewing older adults as worthwhile members of society regardless of their physical limita- tions. Treating all people with dignity is an important aspect in maintaining a person’s quality of life. Every- one deserves that.
Social Policy Implications One recurring theme in this chapter is the problem of financing health care interventions in later life for people in the United States. The Current Controver- sies feature raises several key points about the costs of nursing homes in the United States and the lack of ways to finance those costs. With the aging of the baby-boom generation, it is possible the com- ing wave of older adults will be unable to afford the level and quality of care they expect to receive.
This is not the way it is in other countries. For example, U.S. health care expenditures as a per- centage of its gross domestic product are nearly 5 times greater than they are in Singapore, but Singapore’s health care is more effective as mea- sured by the World Health Organization in terms of health attainment of the average resident, afford- ability, and responsiveness (Murray & Evans, 2003). As such, mere expenditures are not a good indica- tor of quality.
International funding models for long-term care reflect a wide variety of approaches, including social insurance, universal coverage through public services, financial need based systems, and hybrid approaches. Similarly, there is an equally wide array of ways for limiting expenses. Many countries pro- vide services ranging from in-home care through skilled nursing care, and have formal evaluation procedures to determine the best approach to care for each individual.
It is clear there is an array of successful mod- els of providing long-term care to older adults that range from those completely supported by taxes to those that combine public and private contributions. Each has advantages (and disadvantages) that could inform discussions in the United States. It is equally clear the current U.S. model is not sustainable finan- cially, and without serious attention there will be major difficulties faced by the coming generation of aging baby boomers.
Adult Development in Action As a nursing home administrator, what changes would you predict in resident demographics, nursing home design, and the types of services offered based on what you know about the aging population?
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154 CHAPTER 5
5.2 The Ecology of Aging: Community Options
What is aging in place? Aging in place reflects the balance of environmen-
tal press and competence through selection and compensation. Feeling “at home” is a major aspect of aging in place.
Throughout adulthood people compensate for change; aging in place represents a continuation of that process.
Aging in place has resulted in a rethinking of hous- ing options for older adults.
How do people decide the best option? The best placement options are based on whether
a person has cognitive or physical impairment, the ability of family or friends to provide support, and whether intervention, if needed, can be provided in the current residence or a move is necessary.
How can a home be modified to provide a supportive environment?
Modifying a home can be a simple process (such as adding hand rails in a bathroom) or extensive (such as modifying doorways and entrances for wheel- chair access).
Home modifications are usually done to address difficulties with activities of daily living (ADLs).
What options are provided in adult day care? Adult day care provides support, companionship,
and certain types of services. Programs include social, health care, and specialized services.
Introduction of adult day care needs to be done carefully with persons who have cognitive impair- ment.
What is congregate housing? Congregate housing includes a range of options,
that provide social support and meals, but not ongoing medical care.
What are the characteristics of assisted living? Assisted living provides options for adults need-
ing a supportive living environment, assistance with activities of daily living, and a modest level of medical care.
Assisted living situations have three essential attributes: a home-like environment; the philoso- phy of care emphasizes personal control, choice, and dignity; and facilities meet residents’ routine services and special needs.
Summary 5.1 Describing Person–Environment Interactions
What is the competence–environmental press model? Competence is the upper limit on one’s capacity to
function. Environmental press reflects the demands placed
on a person. Lawton and Nahemow’s model establishes points of
balance between the two, called adaptation levels. One implication of the model is the less competent a person is, the more impact the environment has.
People can show proactivity (doing something to exert control over their lives) or docility (letting the situation determine their lives).
What is the proactive and corrective proactivity (PCP) model?
The preventive and corrective proactivity (PCP) model explains how life stressors and lack of good congruence in person–environment interactions, especially when the person has nothing to help buffer or protect against these things, result in poor life outcomes.
Preventive adaptations are actions that avoid stress- ors and increase or build social resources. Corrective adaptations are actions taken in response to stress- ors, and can be facilitated by internal and external resources.
What are the major aspects of stress and coping theory relating to person–environment interaction?
Schooler applied Lazarus’s model of stress and coping to person–environment interactions. Schooler claims older adults’ adaptation depends on their perception of environmental stress and their attempts to cope. Social systems and institu- tions may buffer the effects of stress.
What are the common themes in the theories of person–environment interactions?
All theories agree the focus must be on interac- tions between the person and the environment. No single environment meets everyone’s needs.
Everyday competence is a person’s potential abil- ity to perform a wide range of activities considered essential for independent living.
Everyday competence forms the basis for deciding whether people are capable of making decisions for themselves.
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WHERE PEOPLE LIVE: PERSON–ENVIRONMENT INTERACTIONS 155
How should people communicate with nursing home residents?
Inappropriate speech to older adults is based on stereotypes of dependence and lack of abilities. Patronizing and infantilizing speech are examples of demeaning speech, that are rated negatively by older adults. The communication enhance- ment model has been proposed as a framework for appropriate exchange. This model is based on a health promotion model that seeks opportuni- ties for health care providers to optimize outcomes for older adults through more appropriate and effective communication.
How is decision-making capacity assessed? The Patient Self-Determination Act (PSDA) requires
people to complete advance directives when admit- ted to a health care facility. A major ethical issue concerns how to communicate this information to people with cognitive impairment in nursing homes.
What are some new directions for nursing homes? The Eden Alternative, the Green House concept,
and the Pioneer Network have a commitment to viewing older adults as worthwhile members of society regardless of their physical limitations.
Review Questions 5.1 Describing Person–Environment Interactions
What are person–environment interactions? Describe Lawton and Nahemow’s theory of environ-
mental press. In their theory, what is adaptation level? Describe the preventive and corrective proactivity
(PCP) model. Describe the application of the stress and coping
model to person–environment interactions. What kinds of things buffer stress?
What are the common themes expressed by the var- ious theories of person–environment interactions?
What are the key components of everyday compe- tence?
5.2 The Ecology of Aging: Community Options What is aging in place? What factors should people use to make decisions
about the most supportive environment in which to live?
Research shows assisted living is especially helpful for frail older adults.
5.3 Living in Nursing Homes At any given time, only about 5 % of older adults are
in nursing homes. Such facilities are excellent exam- ples of the importance of person–environment fit.
What are the major types of nursing homes? A distinction within nursing homes is between
skilled nursing care and intermediate care. Costs of nursing home care are high, and only
certain types of insurance cover part of the costs. Future funding is a major concern.
Who is likely to live in nursing homes? The typical resident is female, European Ameri-
can, very old, financially disadvantaged, wid- owed/divorced or living alone, has no children or family nearby, and has significant problems with activities of daily living. However, the num- ber of minorities in nursing homes is increasing rapidly.
Placement in nursing homes is seen as a last resort and is often based on the lack of other alternatives, lack of other caregivers, or policies governing the level of functioning needed to remain in one’s pres- ent housing. It often occurs quickly in the context of a medical crisis.
What are the key characteristics of nursing homes? Selection of nursing homes must be done carefully
and take the person’s health conditions and finan- cial situation into account.
Person-centered planning is the best approach, espe- cially for people who have cognitive impairment.
What are special care units? Special care units provide a supportive environment
for people with specific problems such as dementia. Residents of special care units tend to be younger
and more impaired than the rest of the nursing home residents.
Can a nursing home be a home? Residents of nursing homes can come to the con-
clusion that this can be home. Home is more than simply a place to live: Coming to the feeling that one is at home sometimes entails reflection on what one’s previous home was like and recogniz- ing a nursing home can have some of the same characteristics.
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156 CHAPTER 5
for people who need assistance with personal care (such as bathing or taking medications) but are not so impaired physically or cognitively they need 24-hour care.
competence In the Lawton and Nahemow model, the theoretical upper limit of a person’s ability to function.
corrective adaptations Actions taken in response to stressors and can be facilitated by internal and external resources.
docility When people allow the situation to dictate the options they have and exert little control.
ecology of aging Also called environmental psychol- ogy, a field of study that seeks to understand the dynamic relations between older adults and the envi- ronments they inhabit.
environmental press In the Lawton and Nahemow model, the demands put on a person by the environment.
everyday competence A person’s potential ability to perform a wide range of activities considered essential for independent living.
infantilization or elderspeak Also called secondary baby talk, a type of speech that involves the unwar- ranted use of a person’s first name, terms of endear- ment, simplified expressions, short imperatives, an assumption that the recipient has no memory, and cajoling as a means of demanding compliance.
patronizing speech Inappropriate speech to older adults based on stereotypes of incompetence and dependence.
person–environment interactions The interface between people and the world they live in that forms the basis for development, meaning behavior is a func- tion of both the person and the environment.
preventive adaptations Actions that avoid stressors and increase or build social resources.
proactivity When people choose new behaviors to meet new desires or needs and exert control over their lives.
zone of maximum comfort In competence–environ- mental press theory, the area where slight decreases in environmental press occur.
zone of maximum performance potential In competence–environmental press theory, the area where increases in press tend to improve performance.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
How can homes be modified to support older adults? What is an auxiliary dwelling unit?
What services are provided at adult day care centers?
What is congregate housing? What services are provided at assisted living
facilities?
5.3 Living in Nursing Homes How many older adults live in long-term care facili-
ties at any given time? What types of nursing homes are there? Who is most likely to live in a nursing home? Why? How have the characteristics of nursing homes
been studied? Why do special care units often reflect better place-
ment for people with significant physical or cogni- tive impairment?
How does a resident of a nursing home come to view it as a home?
What are the characteristics of inappropriate speech aimed at older adults? What is an alterna- tive approach?
How does the Patient Self-Determination Act relate to residents’ decision-making capacity?
What do the Eden Alternative, the Green House concept, and the Pioneer Network have in common?
INTEGRATING CONCEPTS IN DEVELOPMENT What do the demographics about the aging of
the population imply about the need for long- term care through the first few decades of the 21 st century?
How do the theories of person–environment inter- action include the basic developmental forces?
How might a better financing arrangement for alternative living environments be designed?
KEY TERMS adaptation level In Lawton and Nahemow’s model, the point at which competence and environmental press are in balance.
adult day care Designed to provide support, compan- ionship, and certain services during the day.
assisted living facilities Housing options for older adults that provide a supportive living arrangement
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Attention And Memory
Chapter 6
6.1 INFORMATION PROCESSING AND ATTENTION Information-Processing Model • Attention: The Basics • Speed of Processing • Processing Resources • Discovering Development: How Good Are Your Notes? • Automatic and Effortful Processing
6.2 MEMORY PROCESSES Working Memory • Implicit versus Explicit Memory • Long-Term Memory • Age Differences in Encoding versus Retrieval
6.3 MEMORY IN CONTEXT Prospective Memory • How Do We Know?: Failing to Remember I Did What I Was Supposed to Do • Source Memory and Processing of Misinformation • Factors That Preserve Memory
6.4 SELF-EVALUATIONS OF MEMORY ABILITIES Aspects of Memory Self-Evaluations • Age Differences in Metamemory and Memory Monitoring
6.5 MEMORY TRAINING Training Memory Skills
6.6 CLINICAL ISSUES Normal versus Abnormal Memory Aging • Memory and Physical and Mental Health • Current Controversies: Concussions and Athletes • Memory and Nutrition
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
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158 CHAPTER 6
If You Are Like Most People, You Probably Have Trouble Remembering The Names Of Every Person You Meet. Not Harry Lorayne (born 1926). Harry was able to meet as many as 1500 people for the first time, hear their name once, and remember each one perfectly. The book Ageless Memory (2008) is the culmination of his more than 40 -year career training people how to remember information and dazzling audiences with his own abilities. Thousands of people bought his books and videos and attended his programs.
Why did Lorayne have such an impact? As we shall see, how well we remember things takes on considerable importance in our lives. Memory is such a pervasive aspect of our daily lives and reflects a cognitive ability that is quite public; we use it as a measure for whether our “minds” are still intact. From remembering where we put our keys, cooking our favorite food, and taking our medications, we rely on memory to get us through our day. Most important, we use memory to construct our personal biography; our story gives us a sense of identity. Imagine how frightening it would be to wake up and have no memory what- soever—no recollection of your name, address, parents, or anything else.
Perhaps that is why we put so much value on maintaining a good memory in old age and why memory training, as espoused by Lorayne, is so important. Older adults are stereotyped as people whose memory is on the decline, people for whom forgetting is not to be taken lightly. Many people think forgetting to buy a loaf of bread when they are 25 is all right, but forgetting it when they are 65 is cause for concern (“Do I have Alzheimer’s disease?”). We will see that forgetting is part of daily life, and the belief it only happens in late life is wrong. In fact, older adults are quite adept at using strategies in their everyday life contexts to remember what they need to know.
In this chapter, we focus on both attention and memory, since they go hand in hand. We examine how people process information from the world around them and make sense out of it. We then discover cognition is a highly dynamic thing; lower-order processes such as attention create and influence higher-order thought, and higher- order thought determines where we focus our attention. People need to notice things in order to build knowledge and remember, because what we already know shapes what we notice. Thus, cur- rent research emphasizes changes in the different qualitative ways we process information and the quantitative differences in the amount of process- ing that occurs as we grow older. This research proves the traditional stereotype about memory and aging is wrong.
An important aspect of this research is whether or not we observe age-related decline in cognitive processes such as memory and attention and depends on the type of task being adminis- tered or the context wherein the memory oper- ates. Some tasks, such as memorizing long lists of unrelated words, show large declines in perfor- mance with age, whereas others, such as remem- bering emotionally charged or personally relevant information, show no decline, and at times, improvement with age.
These task-related differences bring us back to the life-span perspective. A key issue is the extent research on attention and memory reflects the everyday cognitive functioning of older adults. In other words, what are the practical implications of age-related changes in cognitive functioning in specific situations? Ha
rr y
Lo ra
yn e
Haaarry LLLorayne
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ATTENTION AND MEMORY 159
he started the engine and eased into first gear, he became filled with utter terror. He suddenly realized he must pay complete attention to what he was doing. Why? The car had—a clutch. He had never driven a manual transmis- sion before. Now he was faced with the need to filter out everything—people’s conversations, the radio, and the sound of the wind whipping through his hair.
How can Trey filter everything out? More importantly, what abilities can he use to pay attention? If something happened on the road, how quickly could he respond? Would these abilities be any different in a younger adult than in an older adult? Have you ever had this experience? If so, how did you access this knowledge?
How do we learn, remember, and think about things? Psychologists do not know for sure. About the best they can do is create models or analogues of how they believe our cognitive processes work. In this section, we consider the most popular model: the information-processing model.
Information-Processing Model The information-processing model uses a computer meta- phor to explain how people process stimuli. As with a computer, information enters the system (people’s brains) and is transformed, coded, and stored in vari- ous ways. Information enters storage temporarily, as in a computer’s buffer, until it becomes stored more perma- nently, as on a computer storage device (USB, hard drive, cloud storage, etc.). At a later time, information can be retrieved in response to some cue, such as a command to open a file. Let’s see how this works more formally.
The information-processing model is based on three long-held assumptions (Neisser, 1976): (1) People are active participants in the process; (2) both quan- titative (how much information is remembered) and qualitative (what kinds of information are remem- bered) aspects of performance can be examined; and (3) information is processed through a series of pro- cesses. First, incoming information is transformed based on what a person already knows about it. The more one knows, the more easily the information is incorporated. Second, researchers look for age differ- ences in both how much information is processed and what types of information are remembered best under various conditions. Third, researchers in adult devel- opment and aging focus on several specific aspects of information processing: early aspects, including a brief
We use memory not only as an end, when the goal is what and how much we remember, but also as a means to an end. For example, we use mem- ory as an end when we summarize the most recent episode of our favorite television show, tell other people about ourselves, or remember to make spe- cific points in a discussion. In these situations we use memory, but the point is not just what or how much we remember. In these and many other situ- ations, memory is also a means to facilitate social exchange, allow other people to get to know us, or give ourselves a shared past with others. We return to this idea when we examine cognition in context later in the chapter.
Throughout this chapter, we consider results from experiments with responses made by people using computers. Although there is substantial evidence for age differences in some of the ways young and older adults process information, part of the difference may be due to cohort effects (see Chapter 1 ). Specifically, older adults in general are much less used to working on computers than younger adults, making the task less familiar to older adults. Consequently, they may not perform up to their maximum. Whether this experiential difference accounts for part of the age differences researchers uncovered remains to be seen; how- ever, given the research is cross-sectional, meaning that age and cohort effects are confounded (see Chapter 1 ), this explanation remains a possibility.
6.1 Information Processing and Attention LEARNING OBJECTIVES
What are the primary aspects of the information- processing model?
What are the basic components of attention? How does speed of processing relate to cognitive
aging? What types of processing resources relate to
attention and memory? What is automatic and effortful processing?
Trey strolled into a car dealership and convinced the salesperson to let him take one of the sports cars on the lot for a spin around the block. When he climbed behind the wheel, his excitement almost got the better of him. As
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160 CHAPTER 6
functional perspective (McDowd & Shaw, 2000). From the functual perspective, attention is composed of sep- arate dimensions serving different functions. The com- plex tasks we engage in when processing information usually require more than one attentional function. In Trey’s case, he must selectively attend to or focus on the clutch, shifting gears, the road and its obstacles, and at the same time filter out distracting information. This kind of changing focus is how we control attention. In addition, attentional processes are influenced by the capacity to sustain attention, as well as the speed that information is processed.
Attentional control is linked to the processes in the parieto-frontal lobes discussed in Chapter 2 (Ptak, 2012). As we know, the parieto-frontal integration processes undergo significant change with age. Not surprisingly, then, age differences emerge in various aspects of attention. Let’s consider these in more detail.
Speed of Processing Imagine you are sitting quietly watching a video on your iPad. Suddenly, the fire alarm goes off. How quickly can you respond?
That quick response refers to a notion in cognitive psychology known as speed of processing. Speed of processing is how quickly and efficiently the early steps in information processing are completed.
At one time, researchers believed decline in speed of processing explained age-related changes in cogni- tive functioning (e.g., Salthouse, 1996). This theory generally fell out of favor because research shows
sensory memory and attention; and active process- ing that transfers information into a longer term store (e.g., long-term memory).
Using the information-processing model poses three fundamental questions for adult development and aging: (1) What areas of information processing show evidence of age differences (e.g., early stages of processing such as attention, working memory, long- term memory)? (2) How can we explain variability when we find age differences in information process- ing? (3) What are the practical implications of age- related changes in information processing?
Sensory Memory. All memories start as sensory stimuli—a song heard, a person seen, a hand felt. We need to experience these things for only a small frac- tion of a second in order to process the information. This ability is due to the earliest step in information processing, sensory memory, where new, incoming information is first registered. Sensory memory is a brief and almost identical representation of the stim- uli that exists in the observable environment. Sensory memory takes in large amounts of information rapidly. It does not appear to have the limits other processes do when attentional focus is applied. This type of memory is as if the representation exists in your mind in the absence of the stimuli itself.
However, unless we pay attention to sensory infor- mation, the representation will be lost quickly. Try drawing either side of a U.S. penny in detail. (Those who are not from the United States can try drawing a common coin in their own country.) Most of us find this task difficult despite seeing the coins every day. Much detailed information about pennies has passed through our sensory memory repeatedly, but because we failed to pay attention, it was never processed to a longer lasting store. Age differences are not typically found in sensory memory (Nyberg, Lövdén, Riklund, Lindenberger, & Bäckman, 2012).
Attention: The Basics Each of us have experienced being in a situation when our thoughts drift off and someone snaps at us, “Pay attention to me.” We come back into focus, and realize we had not been paying attention.
But what exactly does it mean to “pay attention?” One way to look at it is to think of attention from a
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ATTENTION AND MEMORY 161
thoughts and improve performance on everyday tasks for middle-aged and older adults.
There are simple strategies to compensate for older adults’ difficulties with inhibiting irrelevant information. For example, simply asking older adults to close their eyes or avert their gaze away from irrel- evant information improves performance. Using this strategy, older adults were just as good as young adults in attending to auditory stimuli (Einstein, Earles, & Collins, 2002).
Finally, researchers are asking whether there is a beneficial effect for the lack of inhibition of informa- tion under the right circumstances. It turns out there is. When information that was initially distracting but later became relevant, older adults performed bet- ter than young adults (Kim, Hasher, & Zacks, 2007; Thomas & Hasher, 2012). In such cases, the inability to inhibit distracting information turned into an advan- tage as the nature of relevant information changed.
Once again, we embrace a life-span perspective: adult developmental changes in cognitive function- ing are characterized by both gains and losses. It is important to consider inhibitory loss in both ways. Under certain conditions it can be a hindrance, and in others it can be helpful. It all depends on the situ- ation (Healey, Campbell, & Hasher, 2008; Thomas & Hasher, 2012).
Attentional Resources. Another way of looking at processing resource issues is through the lens of atten- tion. In particular, a key issue is how well adults can perform more than one task at a time. Such multi- tasking requires us to spread our attention across all the tasks. Divided attention concerns how well people perform multiple tasks simultaneously. Driving a car is a classic divided attention task—you pay attention to other cars, the gauges in your car, pedestrians along the side of the street, and perhaps your passengers as you have a conversation with them.
Although it is widely believed older adults have more trouble than younger adults at dividing attention, it turns out the age differences observed are due to older adults’ difficulties with the individual tasks and not to spreading their attention across them per se (Rizzuto, Cherry, & LeDoux, 2012). Observations in the work- place show older workers are just as able to multitask, but perform each task a bit more slowly than younger
whether or not you observe slowing depends on what the task is because all components of mental process- ing do not slow equivalently.
Evidence including neuroimaging studies indi- cates age-related slowing depends on what adults are being asked to do (e.g., choosing which response to make; Dirk & Schmiedek, 2012; Grady, 2012; Nyberg et al., 2012). Interestingly, the amount of beta-amyloid protein found in the central nervous system, a bio- marker linked with the possible subsequent develop- ment of dementia (see Chapter 2 ), has been shown to be related to the degree processing speed slows (Rodrigue, Kennedy, Devous, Rieck, Hebrank, Diaz- Arrastia et al., 2012).
Processing Resources Many theorists and researchers believe with increas- ing age comes a decline in the amount of cognitive “energy” one deploys on a task. This idea is described in terms of processing resources. Processing resources refers to the amount of attention one has to apply to a particular situation.
The idea of a decline in general processing resources is appealing because it would account for poorer performance not only on attention but also on a host of other areas (Dirk & Schmiedek, 2012). How- ever there is a nagging problem about the processing resource construct: At this general level it has never been clearly defined and is too broad. Two more pre- cise approaches to processing resources are inhibitory loss and attentional resources.
Inhibitory Loss. One popular hypothesis is older adults have reduced processing resources because they have difficulty inhibiting the processing of irrelevant information (Aslan & Bäuml, 2012). Evidence indi- cates the oldest-old (people aged 85 or older) have more task-irrelevant thoughts during processing and have trouble keeping them out of their minds. This dif- ference could explain why they tend to have trouble with changing and dividing their attention.
The inhibition idea has considerable support (Kim- bler, Margrett, & Johnson, 2012). Not only do older adults have difficulty inhibiting irrelevant information in laboratory tasks, it matters with respect to everyday problem-solving. Kimbler and colleagues (2012) showed emotionally supportive messages reduce distracting
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162 CHAPTER 6
Automatic and Effortful Processing There are two other constructs that round out our understanding of attention and cognitive process- ing: automatic and effortful processing. Automatic processing places minimal demands on attentional capacity and gets information into the system largely without us being aware of it. Some automatic processes appear to be “prewired” in the sense they require no attentional capacity and do not benefit from practice; others are learned through experience and practice (Apperly, 2012). For example, those who have been driving a car for many years stop at a stop sign without really thinking about it. We will see that performance on tasks that depend on automatic processes do not demonstrate significant age differences.
In contrast, effortful processing requires all of the available attentional capacity. Most of the tasks involv- ing deliberate memory, such as learning the words on a list, require effortful processing. In these cases, we are typically aware of what we are doing. When we first learn how to drive a car with a clutch, we are aware of the information we process (e.g., how much to let up on the clutch versus how hard to press the accelerator pedal). It is with effortful processing that age differ- ences tend to emerge.
Finally, when considering attentional resources, it is extremely important to ask the question: Is attention a fixed capacity that decreases with age? Researchers observed decline in older adults’ per- formance on laboratory tasks assessing memory. However, a different picture may emerge when we consider the functional capacity or resources nec- essary in specific task contexts can be modified depending on the relevance, accessibility of knowl- edge, and expertise related to the cognitive processes required (Hertzog, 2008). Under conditions where the task requirement is to simply have a familiarity with the information, there are no age differences. However, when there is effort and deliberate pro- cessing involved to remember the information, age differences emerge. Because age differences are sen- sitive to the conditions under which they are mea- sured, the key question for researchers today is: When and under what circumstances will we observe age-related change in cognitive functioning, and when is that change problematic?
workers. However, when the tasks become complex, older adults encounter difficulties dividing their atten- tion and their performance suffers as a result.
Age differences on divided-attention tasks can be minimized if older adults are given training, thereby reducing the demands on attention. Such training can even be through online computer games (van Muijden, Band, & Hommel, 2012). These results imply that older adults may be able to learn through experience how to divide their attention effectively between tasks. Check out this idea by completing the Discovering Develop- ment feature.
DISCOVERING DEVELOPMENT: HOW GOOD ARE YOUR NOTES? Divided attention tasks are encountered all the time. You are familiar with one of them—taking notes while listening to a lecture (either on video or live). An interesting developmental question is whether the quality of the notes differs with age. One way to find out informally is to compare the notes taken in the same class by younger and older students. If there are no older adults in your class, there may be some in other courses. Ask them if you can compare their notes with those of someone younger. What predictions would you make based on the research evidence you have read thus far? What role would practice play in these differences? Whose notes are actually better? Why do you think this is?
So, you may ask, when do older adults have dif- ficulty performing multiple tasks simultaneously? You may have observed older adults having difficulty trying to remember something as they are walking down a staircase, or trying to simply walk and talk at the same time. Li and colleagues (Li et al., 2001) found older adults prioritize walking and maintaining balance at the expense of memory. In other words, older adults focused on the task most important to them; walking and balancing to prevent falls. Younger adults, on the other hand, optimized their memory performance and ignored walking and balancing. Older adults and chil- dren perform more poorly than younger adults when executing a memory task while walking (Krampe, Schaefer, Lindenberger, & Baltes, 2011).
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ATTENTION AND MEMORY 163
To successfully complete the task, you have to use your working memory. Working memory is the active processes and structures involved in holding information in mind and simultaneously using that information, sometimes in conjunction with incoming informa- tion, to solve a problem, make a decision, or learn new information.
Researchers typically consider working memory an umbrella term for many similar short-term holding and computational processes relating to a wide range of cognitive skills and knowledge domains (Baddeley, 2012). This places working memory right in the thick of things—it plays an active, critical, and central role in encoding, storage, and retrieval.
Recall that sensory memory has a large capacity to deal with incoming information. In contrast, research- ers generally agree working memory has a relatively small capacity. This capacity limitation of working memory operates like a juggler who can only keep a small number of items in the air simultaneously.
Because working memory deals with information being processed right at this moment, it also acts as a kind of mental scratchpad. This means unless we take direct action to keep the information active, the page we are using will be used up quickly and tossed away. For this reason, we need to have some way to keep information in working memory. That process is known as rehearsal. Rehearsal is the process that infor- mation is held in working memory, either by repeating items over and over or by making meaningful connec- tions between the information in working memory and information already known.
Most evidence indicates there is significant age- related decline in working memory (McCabe & Loaiza, 2012), although the extent of the decline is still in doubt. These data are important because working memory is the key to understanding age differences in memory. The loss of some of the ability to hold items in working memory may limit older adults’ overall cogni- tive functioning. If information becomes degraded or is only partially integrated into one’s knowledge base due to problems in working memory, it will be difficult to remember it.
However, some evidence suggests age differences in working memory are not universal. Working mem- ory appears to depend on the type of information being
6.2 Memory Processes LEARNING OBJECTIVES
What is working memory? What age differences have been found in working memory?
How does implicit memory and explicit memory differ across age?
Within long-term memory, how does episodic and semantic memory performance differ across age?
What age differences have been found in encoding versus retrieval?
Susan is a 75 -year-old widow who feels she does not remember recent events, such as if she took her medi- cine, as well as she used to. She also occasionally forgets to turn off the gas on her stove and sometimes does not recognize her friend’s voice on the phone. However, she has no trouble remembering things from her 20 s. Susan wonders if this is normal or if she should be worried.
Memory researchers have long focused on three general steps in memory processing as potential sources of age differences: encoding, storage, and retrieval (Weis- berg & Reeves, 2013). Encoding is the process of getting information into the memory system. Storage involves the manner in which information is represented and kept in memory. Getting information back out of memory is termed retrieval . Because there is no evidence for age dif- ferences in how information is organized in storage, most research has examined encoding and retrieval as sources of age differences (Naveh-Benjamin & Ohta, 2012).
Working Memory Think about a time when you asked a friend for their mobile phone number so you could send them text messages. You don’t have a pen and paper, and you don’t have an app like Bump on your phone to help. So you work to keep the phone number in your mind until you can type it in.
Adult Development in Action If you are an employee at an Apple store who shows people how to use the new device they bought, what principles would you apply from this section when instructing older adults?
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164 CHAPTER 6
many exceptions and qualifications to this conclusion (Light, 2012). This research typically concerns our next topic, long-term memory.
Long-Term Memory When most people think about memory, they think about having to remember something over time, whether a few minutes or many days. Everyday life is full of examples—remembering routines, perform- ing on an exam, summarizing a book or movie, and remembering an appointment. These types of situa- tions constitute what memory researchers call long- term memory (Rutherford, Markopoulos, Bruno, & Brady-Van den Bos, 2012). Long-term memory refers to the ability to remember rather extensive amounts of information from a few seconds to a few hours to decades.
Memory researchers have created a wide variety of tasks requiring individuals to remember all sorts of information for varying lengths of time. Well over a century of research indicates long-term memory rep- resents a relatively large-capacity store where informa- tion can be kept for long periods. Mounting evidence in cognitive neuroscience suggests long-term memory is not a unitary construct, but consists of distinct, func- tionally different multiple systems and are served by different brain structures (see Chapter 2 ).
As we delve into the various aspects of long-term memory, let us focus first on the more deliberate and effortful systems of explicit long-term memory. Two important types of long-term memory are semantic and episodic memory. Semantic memory concerns learning and remembering the meaning of words and concepts not tied to specific occurrences of events in time. Examples of semantic memory include knowing the definitions of words in order to complete cross- word puzzles, being able to translate this paragraph from English into French, and understanding what the instructor is saying in a lecture.
Episodic memory is the general class of memory having to do with the conscious recollection of informa- tion from a specific event or point in time. Examples of episodic memory include learning the material in this course so you will be able to reproduce it on an examination in the future, remembering what you did on your summer vacation last year, and memorizing a speech for a play.
used and may vary across different tasks (McCabe & Loaiza, 2012). For example, age-related decline in spa- tial working memory tends to be greater than that in verbal working memory, although there is decline in both types of working memory (Oosterman, Morel, Meijer, Buvens, Kessels, & Postma, 2011).
Why does working memory ability decline with age? There are several reasons, including alertness at different times of the day, order of the tasks, and task interference (Rowe, 2011). Another idea is older adults have more trouble juggling all of the elements once they are accessed (McCabe & Loaiza, 2012).
Although the evidence for age-related decline in working memory is not entirely clear, there is compelling evidence for how age differences in working memory relate to performance on more complex cognitive tasks. For example, researchers have begun to show working memory may be key to understanding the age differ- ences in recall performance (McCabe & Loaiza, 2012).
Implicit versus Explicit Memory In addition to working memory, we can further divide memory systems into two other types: implicit mem- ory and explicit memory. Implicit memory (some- times called procedural memory) involves retrieval of information without conscious or intentional recollec- tion. Explicit memory (sometimes called declarative memory), is intentional and conscious remembering of information learned and remembered at a specific point in time.
Implicit memory is much like getting into a routine—we do things from memory but we do not have to think about them. The exact way we brush our teeth tends not to be something we consciously think about at the time. We just remember how to do it. Whether age differences in implicit memory are observed depend on the specific kind of implicit memory task in question (Howard & Howard, 2012). Learning sequences tend to show age differences, whereas learning spatial context does not. Interest- ingly, neuroscience imaging research shows the kind of over- activity in the frontal cortex in older adults that is typical in situations when older adults are compensat- ing for declines (see Chapter 2 for more details).
By far, most research on memory aging focuses on explicit memory. In general, performance on explicit memory tasks declines with age, although there are
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ATTENTION AND MEMORY 165
Older adults not only experience more TOT’s, but also report less partial information about the target, both in the laboratory and in everyday life (Facal, Jun- cos-Rabadán, Rodriguez, & Pereiro, 2012). Such TOT problems indicate even highly familiar information can become more difficult to retrieve as we grow older.
Episodic Memory. Because episodic memory includes so many of the day-to-day activities adults perform, it has been the focus of more research than any other single topic in memory development (Light, 2012; Morcom & Friston, 2012). Typically, researchers study episodic memory by having people learn information, such as a list of words, and then asking them to recall or recognize the items. In a recall test, people are asked to remember information without hints or cues. Everyday examples of recall include telling everything you can remember about a movie or taking an essay exam with no notes or access to materials. Recognition, on the other hand, involves selecting previously learned infor- mation from among several items. Everyday examples of recognition include taking multiple-choice tests and picking out the names of your high school friends from a complete list of your classmates.
Many factors influence adults’ performance on episodic memory tests, and whether age differences are found. Consider how the information to be learned is presented (organized with cues may be better than randomly), how fast it is presented (slower may be bet- ter), how familiar people are with the material (familiar may be better), and how the test is given (recognition is usually better) all make a difference.
The results from hundreds of studies point to sev- eral conclusions. Overall, older adults perform worse than younger adults on recall tests of episodic memory because they omit more information, include more intrusions, and repeat more previously recalled items (Light, 2012; Morcom & Friston, 2012).
On recognition tests, differences between older and younger adults are reduced. However, in compari- son with young adults, older adults are more likely to say they recognize items that were never-presented, especially if they share a conceptual meaning or per- ceptual resemblance to the items actually presented (Light, 2012).
One thing that helps people remember informa- tion in episodic memory tests is using internal study strategies, such as rehearsal or organizing information
Like implicit versus explicit memory, episodic and semantic memory appear to be impacted differ- ently by aging (Rönnlund, Nyberg, Bäckman, & Nils- son, 2005; Spaniol & Voss, 2006). Episodic memory stays fairly stable until around 55 – 60 years of age and then shows a precipitous decline beginning around age 65 . In contrast, semantic memory increases from 35 – 55 years of age and then levels off. Although seman- tic memory starts to decline at age 65 , the decline is much less substantial than for episodic memory (Rönnlund et al., 2005).
Semantic Memory. As indicated previously, semantic memory is relatively spared in normal aging. Evidence suggests there are no deficits in semantic memory pro- cesses such as language comprehension, the structure of knowledge, and the activation of general knowledge (Grady, 2012; Nyberg et al., 2012). Semantic memory retrieval typically does not tax working memory, and thus older adults can draw upon experience in word meanings and/or general world knowledge. In addi- tion, whereas retrieval of episodic memories is based on cues to the original experience, semantic memories are retrieved conceptually as part of our world knowledge. This connection between semantic memory and world knowledge will come up again in Chapter 7 when we consider certain types of intelligence show little, if any, decline with age.
However, research also shows age changes in semantic memory can happen if it becomes hard to access and retrieve. One reason for access problems is if the knowledge in semantic memory is not used on a regular basis (Hertzog et al., 2003). You may have experienced this already, if you learned another lan- guage in childhood, but now have trouble with it if you didn’t use it.
A second reason is simple momentary retrieval failure for information that is otherwise accessible. A common example is when adults have a “tip-of- the-tongue” experience (Brown, 2012). A tip-of-the- tongue (TOT) experience is when you try to retrieve a name or word you are certain you know, but it is not quite accessible at the moment. Imagine you are at a party and see someone familiar; you “know” that per- son’s name, but you simply cannot retrieve it. Another aspect of this TOT experience is you can retrieve par- tial information such as the number of syllables in that person’s name, the initial sounds or letters.
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166 CHAPTER 6
remembering later. So, at least part of the reason older adults perform more poorly than younger adults on tests of memory recall is because of poorer encoding.
Retrieval. We have already seen one of the most supported research findings is older adults do more poorly than younger adults at recalling information. Besides potential encoding difficulties, what else might account for this difference?
Research evidence clearly points to the fact older adults tend to spontaneously use fewer retrieval strate- gies (Hertzog et al., 2013; Light, 2012). Moreover, even when encoding strategies are provided, and the oppor- tunity to apply them during recall is allowed, older adults still do worse.
Based on extensive research evidence, research- ers generally concluded most of the reason memory performance declines with age has to do with retrieval problems (e.g., Hertzog et al., 2013).
Neuroscience Evidence. Cognitive neuroscience (discussed in Chapter 2 ) presents evidence suggesting age differences in encoding and retrieval. Neuroim- aging studies indicate during encoding, older adults’ prefrontal cortex shows over-activity, indicating the usual pattern of compensatory processes with age (see Chapter 2 for more details) (Kalpouzos & Nyberg, 2012; Kalpouzos, Persson, & Nyberg, 2012).
In terms of retrieval, neuroimaging studies show age-related differences in how the prefrontal cor- tex and hippocampus work together (Giovanello & Schacter, 2012). In younger adults, activity in these areas depends on the extent the retrieval task requires relations to be made between the informa- tion being remembered, whereas activity in these regions in older adults stayed equivalent irrespec- tive of relational processing. Other research indicates age-related compensatory brain activity for retrieval, similar to that seen in other cognitive processing (Oedekoven, Jansen, Kircher, & Leube, 2013). Spe- cifically, younger adults have extensive neural net- work connections in the parietal and frontal regions involved in retrieval than older adults. However, older adults show higher levels of brain activity in these regions, indicating a likely compensatory strat- egy for less extensive networks.
Overall, these data support the view, described in Chapter 2 , that older adults process information in
into categories. Older adults tend to be less efficient at spontaneously using these strategies. But they can and do use them when instructed to do so, and show sig- nificant improvement in performance. However, these improvements are not sufficient, in general, to elimi- nate age differences in recall, indicating age differences in recall of episodic information is caused more by retrieval problems than poor encoding during study (Hertzog, Fulton, Mandviwala, & Dunlosky, 2013).
Age differences between older and younger adults can be reduced (but not eliminated) in several other ways: allowing older adults to practice or perform a similar task before learning a new list; using material more familiar to older adults; and using compensatory strategies to help themselves remember (we will exam- ine this later in the chapter).
Although it would be easy to conclude episodic memory does nothing but decline with age, that would be wrong. It turns out there is one episodic memory process relatively spared with age: autobiographical memory, that we will consider a bit later.
Age Differences in Encoding versus Retrieval
As we saw earlier, encoding is the process of getting information into memory, and retrieval is the process of getting that information out. What key changes occur in these processes with age?
Encoding. Results from years of research suggest an age-related decrement in encoding processes (Craik & Rose, 2012). The most important reason for these changes is adults’ spontaneous use of strategies dur- ing the learning of new information declines with age. A strategy is anything people do to make the task easier and increase the efficiency of encoding or retrieval.
Compared to younger adults, older adults tend not to behave as strategically when studying informa- tion to be remembered (Dunlosky, Bailey, & Hertzog, 2011). However, when instructed or taught to do so, older adults can use encoding strategies well. So, the age changes observed reflect more a decrease in the degree the strategies are used spontaneously, rather than a decrease in the ability to use strategies.
Certainly, if information does not get encoded well, it is less likely to be there or to be as accessible for
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ATTENTION AND MEMORY 167
trouble remembering the details of recently learned information. This difference in memory ability has been the focus of research on age differences and how memory operates in everyday life (Dismukes, 2012; Ossher, Flegal, & Lustig, 2013).
This research is extremely important for three reasons. First, it may shed some light that generalize findings based on laboratory tasks such as word-list recall. Second, new or alternative variables affect- ing performance could be uncovered, such as factors that enhance memory functioning in older adults could be identified. Third, research on everyday memory may force us to re-conceptualize memory itself.
Prospective Memory One area receiving increasing attention is prospective memory. Prospective memory involves remembering to remember something in the future, such as an action or event (Dismukes, 2012). Everyday life is full of examples, such as remembering to pick up one’s chil- dren after school and remembering you have a dinner date next Friday evening.
A theoretical model of how prospective mem- ory works is shown in Figure 6.1 (Zogg, Woods, Sauceda, Wiebe, & Simoni, 2012). Note the process starts with the intention to remember something in the future, and depends critically on monitor- ing both event and time cues. This distinction, first introduced by Einstein and McDaniel (1990), is critical for understanding why people do and do not perform the actual task they are attempting to remember to do.
In event-based tasks, an action is to be performed when a certain external event happens, such as giving a certain person a message when they provide a secret word. A time-based task involves performing an action after a fixed amount of time, such as remembering an appointment at 1 : 00 pm.
Researchers found time-based tasks showed more age differences as long as people used self-generated strategies to remember, as these tend to decline with age; the cues that typically accompany event-based tasks helped reduce or eliminate age differences (Rummel, Hepp, Klein, & Silberleitner, 2012). Adults of all ages benefit from the use of reminders, but older adults especially benefit from clear prioritization of
their brains differently than younger adults. These dif- ferences in part represent attempts at working around, or compensating for, the normal age-related changes occurring in information processing.
In summation, the research on encoding and retrieval processes is important for two key rea- sons. First, it emphasizes age-related decrements in memory are complex; they are not due to changes in a single process. Second, memory intervention or training programs must consider both encoding and retrieval.
Adult Development in Action Suppose you are a geriatric physician. Based on what you learned in this section, what would be a good way to test for normative age-related changes in memory?
6.3 Memory in Context LEARNING OBJECTIVES
What age differences are there in prospective memory?
How does autobiographical memory change across adulthood?
How does source memory and processing of misinformation change across adulthood?
What are some factors that preserve memory as we grow older?
Tyler, an elderly man of 80 , has exercised his memory abilities since he reached his 60th birthday. He made sure to read voraciously, done crossword puzzles reli- giously, and kept up on current events. At a recent fam- ily gathering, it was quite evident such behavior paid off. In a game of trivial pursuit, he was the ultimate winner. However, when his grandson told him nonstop about a car he wanted to buy, Tyler later had trouble recalling all of the details.
As noted at the beginning of this chapter, memory is so integral to our everyday life we take it for granted. In the case of Tyler, using his memory of previously studied knowledge proved extremely important in participating in family games. However, he still had
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to remember that fact . Interestingly, little research has been done examining age differences in people’s abil- ity to remember all of the tasks they are supposed to complete have, in fact, been completed. One of these, showing important age differences, is described in the “How Do We Know?” feature.
tasks (i.e., ranking tasks from most to least impor- tant) (Ihle, Schnitzspahn, Rendell, Luong, & Kliegel, 2012).
Of course, it’s clearly important to remember things one is supposed to do in the future. But once all of those tasks are complete, it’s equally important
Intention Formation
Monitoring for Event Cue
Cue Detection and Intention Retrieval
Monitoring for Time Cue
DELAY PERIOD: RETENTION & DISTRACTION
Intention Execution
Intention Recall
Figure 6.1 Conceptual model of the component processes of prospective memory. Source: Zogg, J. B., Woods, S. P., Sauceda, J. A., Wiebe, J. S., & Simoni, J. M. (2012). The role of prospective memory in medication adherence: A review of an emerging literature. Journal of Behavioral Medicine, 35, 47–62. http://link .springer.com/article/10.1007/s10865-011-9341-9/fulltext .html#Sec1, Figure 1.
HOW DO WE KNOW?: FAILING TO REMEMBER I DID WHAT I WAS SUPPOSED TO DO Who were the investigators, and what was the aim of the study? Most research on prospective memory focuses on whether people remember to do something in the future. Scullin, Bugg, and McDaniel (2012) realized it is also important for people to stop doing something once all of the tasks are done. They investigated whether there are age differences in people’s ability to remember to stop doing an action when it is no longer necessary to do it.
How did the investigators measure the topic of interest? The study had two phases. In the first, younger and older adults were told to perform a task, that they subsequently did. In Phase 2 , participants were told the task was finished, yet still received the cue to perform the task, and measured as to whether they still did it despite being told not to.
Who were the participants in the study? Younger adult university students ( average age = 19 years ) and community-dwelling older adults ( average age = 75 years ) participated.
What was the design of the study? The experiment was a 2 × 3 between-subjects design that included age group (younger or older) and condition (nonsalient- cue/task-match, salient-cue/task-match, or salient-cue/ task-mismatch). The nonsalient-cue/task-match condi- tion had a cue that did not signal the need to do the task. The salient-cue/task-match had a cue that was the signal to perform the task. The salient-cue/task-mis- match had the cue that formerly signaled the need to do the task, but no longer indicated that. Participants were randomly assigned to the three conditions.
Were there ethical concerns with the study? There were no ethical concern because all of the participants were volunteers and had the experiment fully explained.
What were the results? In Phase 1, younger and older adults performed equivalently by correctly remembering to perform the task when cued. In Phase 2, though, older adults were more likely to con- tinue attempting to perform the task when the cue occurred even though they had been told it was no longer necessary. Thus, older adults had more errors of commission.
What did the investigators conclude? Careful analyses of the results indicated older adults who
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ATTENTION AND MEMORY 169
details for events would get fuzzier or fewer over time. For many events, that’s true. But, surprisingly, that’s not what always happens.
How memory for details of autobiographical events changes over time can only be studied when an independent record exists, made at the time the events happened. Biological/medical data, such as height or age at menarche (when a girl first menstruates) pro- vide such a source. In a classic study, Casey, Dwyer, Coleman, Krall, Gardner, & Valadian (1991) examined records available from the Harvard Longitudinal Stud- ies of Child Health and Development on individuals from birth to age 50 . Detailed information was col- lected over the years on such things as what childhood diseases the participants had, whether they smoked cigarettes, and what kinds and how much food they ate. At age 50 , participants completed a lengthy ques- tionnaire about these issues, and their responses were compared with similar reports made 10 and 20 years earlier, as well as with the official records. Casey and colleagues found half of the memories elicited at age 50 were more accurate than the memories for the same information elicited 10 years earlier at age 40 . How- ever, information about amounts of food consumed or individual episodes was not remembered well. Appar- ently, these events tend to get blended together and are not stored as separate incidents. Long-term accuracy for medical information has been validated by several other studies (e.g., Kyulo, Knutsen, Tonstad, Fraser, & Singh, 2012).
What distinguishes memorable events from those that aren’t? What makes a moment we will remember the rest of our lives? Many people think highly traumatic or surprising and unexpected events are ones indelibly etched in our memories. Events such as September 11, 2001, or the unexpected death of a loved one are exam- ples. Researchers label memories for personally traumatic or unexpected events flashbulb memories .
Flashbulb memories tend to feel real to people, who believe their recollections are highly accurate down to small details (Neisser, 2012). It turns out, though,
Autobiographical Memory. We noted earlier one main function of memory is to create one’s sense of identity (Prebble, Addis, & Tippett, 2013). In other words, some of the information people learn and keep for a long time concerns information and events that happen to us. When we put all those incidents and information together, we create our autobiography. Autobiographical memory involves remembering information and events from our own life.
Testing autobiographical memory is tricky. To do it correctly requires having independent verification a remembered event actually happened in the way claimed. That’s fine if there is a video of the event. But much of our lives are not on video making it difficult to validate event recall. Plus, just because a person doesn’t remember something could be due to memory failure, certainly, or because they never learned it in the first place. Some ingenious researchers, though, managed to circumvent these problems and figured out how to study autobiographical memory.
Autobiographical memory is primarily a form of episodic memory, although it can also involve seman- tic memory. The episodic component of autobiograph- ical memory is the recollection of temporal and spatial events from one’s past (e.g., birthday parties, vacations, graduations). The semantic component consists of knowledge and facts of one’s past (e.g., personal char- acteristics, knowledge that an event occurred) with- out having to remember exactly what or when things occurred.
Autobiographical memories change over time for all adults, with certain specific details (e.g., what objects are next to each other) being forgotten first, and other information (e.g., the main focus of the event) being remembered best (Talamini & Gorree, 2012). The number of autobiographical memories increases fastest during young adulthood ( ages 18 – 25 ) , especially those involving social interaction (Fuentes & Desrocher, 2012).
As you may have experienced, details for autobio- graphical events change over time. You might think
made commission errors were less able to inhibit the task response than those who did not make commis- sion errors. Inhibition is an important part of execu- tive functioning, the higher level cognitive processes that control decision making (in this case the decision
to complete the task). Additionally, older adults who made commission errors were more likely to get stuck making the task response in ways that implied they might have had trouble stopping even if they wanted to.
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170 CHAPTER 6
from specific years) (Mace & Clevinger, 2013). It may be this earlier period of life contains more key events important in creating one’s personal history (Conway & Holmes, 2004; Pasupathi & Carstensen, 2003).
Source Memory and Processing of Misinformation
Why are some autobiographical memories that seem so vivid actually inaccurate at the detail level? Two main reasons have to do with how we remember the source of information and how susceptible we are to false information.
Source Memory. Think about a familiar event in your life. Now attempt to remember how you obtained your memory of it. Did you actually experience the event? Are you sure?
Source memory refers to the ability to remember the source of a familiar event as well as the ability to determine if an event was imagined or actually expe- rienced . Remembering the source of information is important in many contexts. It is important for peo- ple to be able to discriminate whether they actually remembered to take medication or only thought to do it. The ability to discriminate between these two events requires one to retrieve information about the context in which the event in question originally occurred. By reconstructing the original event accurately, the adults will remember whether they actually took the medica- tion or not.
Research on age differences in source memory reveals older adults are less accurate at a number of source-memory tasks (Dulas & Duarte, 2012; Spaniol & Grady, 2012). The problem appears to be younger adults are better than older adults at connecting the item to be remembered with the context in which it is learned (Boywitt, Kuhlmann, & Meiser, 2012). A large cross-sectional study of source memory with adults between 21 and 80 years revealed a linear decrease in performance, implying the decrements in perfor- mance happen gradually across the adult life span (Cansino, Estrada-Manilla, Hernández-Ramos, Mar- tinez-Galindo, Torres-Trejo, Gómez-Fernández et al., 2013). The main exception to these age differences is when the source memory information is emotional; in some cases both younger and older adults show identi- cal patterns of performance, perhaps because emotional
when researchers compare what people claim they remember with independent records of actual events, the memories are often wrong. Many people feel abso- lutely certain they remember exact details of the events on September 11, 2001. President George Bush often related his detailed recollection of how and what he heard about the terrorist attacks. However, compari- son with actual historical records indicate his memory was inaccurate in important ways concerning the details (Greenberg, 2004). Nevertheless, people tend to get the gist of the story correct, and highly emotional events do tend to be remembered better than unemo- tional ones (Neisser, 2012). The errors and influences on autobiographical memory help explain why eyewit- ness testimony is often unreliable (Roediger, Wixted, & DeSoto, 2012).
Given autobiographical memory is the basis for identity, what events do people remember and when did they occur across the life span? What Susan experi- enced in the vignette, and as can be seen in Figure 6.2 , is typical. For both younger and older adults, when asked to remember life events, vivid memories expe- rienced earlier in life (between 10 and 30 years of age) are reported more often than those occurring during middle adulthood (between 30 and 50 years of age; Fitzgerald, 1999; Willander & Larsson, 2006). Events form less- remembered periods can be recalled if given additional context (such as news headlines
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Figure 6.2 Both younger and older adults remember more life events from their teens and 20s than from any other period of life. Source: Based on Fitzgerald, J. (1999). Autobiographical memory and social cognition. In T. M. Hess & F. Blanchard-Fields (Eds.), Social cognition and aging.
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ATTENTION AND MEMORY 171
about it (Johnson, Raye, Mitchell, & Ankudowich, 2012). Important events may not be remembered at all, or may be remembered with the right kinds of cues. And, even highly emotional events can be accurate or highly inac- curate depending on the circumstances surrounding how they are remembered. Older adults tend to be more sus- ceptible to these issues than younger adults (Benjamin, 2001; Jacoby & Rhodes, 2006; Karpel et al., 2001).
Once again, an explanation for this effect is older adults have more difficulty in correctly identifying information as false because they have trouble link- ing content information to its context, as noted earlier. Moreover, older adults have more difficulty separat- ing misleading context from relevant context, that also explains why older adults are more susceptible to misleading information in general (Jacoby, Rogers, Bishara, & Shimizu, 2012).
Factors That Preserve Memory As indicated by some of the results in everyday mem- ory, older adults perform quite well at certain every- day memory tasks in certain situations. These findings imply there may be specific factors that help preserve memory performance, termed cognitive reserve . Let’s investigate some of them.
Exercise. A major meta-analytic study showed con- clusively physical fitness training improves cognitive performance in older adults regardless of the training method or the older adults’ personal characteristics (Colcombe & Kramer, 2003). Neuroscience research also clearly demonstrates regular exercise has a wide range of effects on the brain, such as increased neural plasticity (i.e., flexibility and adaptability of brain func- tioning), and can be viewed as an intervention alterna- tive for diseases such as Parkinson’s, Alzheimer’s, and stroke, and may prevent some of the normative decline typically associated with aging (Marques-Aleixo, Oliveira, Moreira, Magalhães, & Ascensão, 2012).
Multilingualism and Cognitive Functioning. In an intriguing study, Kavé, Eyal, Shorek, and Cohen- Mansfield (2008) explored whether the number of languages a person speaks positively influences the cognitive state of older adults. In fact, older adults from 75 to 95 years of age who spoke four languages or more showed the best cognitive state. Similarly, Bialystock,
information is processed differently than the informa- tion in pure memory tasks (Nashiro, Sakaki, Huffman, & Mather, 2013).
Benjamin (2010) proposed older adults have a global deficit in memory causing problems in source memory and the inability to exclude irrelevant infor- mation. The Density of Representations Yields Age- related Deficits (DRYAD) model proposes older adults are presumed to have less valid representations of events and objects than are young adults. To date, research support has been obtained in some studies (Benjamin, Diaz, Matzen, & Johnson, 2012).
Neuroimaging research indicates older adults show over-activation of areas in the prefrontal cortex (Giovanello & Schacter, 2012; Spaniol & Grady, 2012), a pattern we saw in Chapter 2 reflecting compensatory behavior. Some research supports the notion the brain regions in which source memory is processed may even change with increasing age (Dulas & Duarte, 2012).
We can relate these findings to the role retrieval cues play in older adults’ memory functioning. Old and Naveh-Benjamin (2008) suggest contextual details can serve as retrieval cues and without access to them older adults may have more difficulty in remembering events. Furthermore, episodic memory is more highly dependent upon contextual information that could explain why older adults have difficulties with that kind of task.
False Memory. At times in our lives, we may be repeatedly told stories about us by relatives or friends that we could not have personally experienced. How- ever, if we hear them enough, we may start believing the events are real and falsely incorporate them into our autobiographical memory. False memory is when one remembers items or events that did not occur.
The focus in false memory research is on memory errors. One way to study false memory in the labora- tory is to present participants with information (e.g., a list of related words, a video of an event) and test people’s memory for both the information actually presented and information that was not (e.g., words related to those in the list but never studied, details that could plausibly have happened in the event but were not actually seen).
People tend to falsely recall and incorrectly rec- ognize such plausible information and feel confident
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172 CHAPTER 6
that aging hampers memory ability (Hess, Auman, Colcombe, & Rahhal, 2003). Specifically, negative or threatening stereotypes suppress older adults’ con- trolled or conscious use of memory while increasing the likelihood they will use automatic response instead (Mazerolle, Régner, Morisset, Rigalleau, & Huguet, 2012). We will explore this psychosocial factor influ- encing cognition in Chapter 8 .
Craik, and Luk (2012) found bilingualism plays a large role in protecting older adults from cognitive decline. These findings suggest speaking multiple languages might be a protective factor for maintaining our cogni- tive state as we age.
Semantic Memory in Service of Episodic Memory. Given that semantic memory is relatively unimpaired as we grow older (as discussed earlier), it may have an enhancement effect on episodic memory for older adults. Several studies show older adults perform better when they can use previously learned semantic informa- tion to support episodic knowledge (Badham, Estes, & Maylor, 2012; Naveh-Benjamin, Craik, Guez, & Kreuger, 2005). The more associations are made, the stronger the effect and the more performance is improved.
Negative Stereotypes and Memory Performance. Older adults may not perform at optimal levels because they are aware of and threatened by the typical belief
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Adult Development in Action How might autobiographical memory be used in therapeutic settings?
6.4 Self-Evaluations of Memory Abilities LEARNING OBJECTIVES
What are the major types of memory self- evaluations?
What age differences have been found in metamemory and memory monitoring?
Eugene just reached his 70 th birthday. However, he is greatly concerned. He believed since he was young this is the age when memory really goes downhill. He has a great fear of losing his memory completely. He asks peo- ple to repeat things to him over and over for fear he will forget them. This fear takes a toll on his self-concept. He doesn’t feel he has control over his life the way he used to.
How good is your memory? Do you forget where you put your keys? Or are you like the proverbial ele- phant who never forgets anything? Like most people, you probably tend to be your own harshest critic when it comes to evaluating your memory performance. We analyze, scrutinize, nitpick, and castigate ourselves for the times we forget; we rarely praise ourselves for all the things we do remember, and continue to be on guard for more memory slips. The self-evaluations we make about memory may affect our daily life in ways traditionally were unrecognized. This is exactly what is happening to Eugene. His negative evaluations of his memory ability are creating much undue stress in his life.
The self-evaluations we make about memory are complex (Cavanaugh, 1996; Castel, McGillivray, &
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ATTENTION AND MEMORY 173
The Role of Memory Self-Efficacy. Belief in one’s ability to accomplish things is an old, pervasive theme in literature, religion, psychotherapy, and many other diverse arenas (Berry, 1999; Cavanaugh & Green, 1990). One of the most beloved children’s books is The Little Engine that Could . The train engine keeps telling itself, “I think I can. I think I can.” and, of course, it performs successfully.
As it applies to memory, belief in oneself is referred to as memory self-efficacy ; it is the belief one will be able to perform a specific task. This is an important construct in understanding how memory changes with age (Berry, West, & Cavanaugh, 2013). Memory self-efficacy is an important type of memory belief dis- tinct from general knowledge about memory; one may know a great deal about how memory works but still believe one’s ability to perform in a specific situation is poor.
Memory self-efficacy emerged as one of the key aspects of metamemory because of its importance in accounting for performance in several different types of situations, as well as helping to explain how people make performance predictions in the absence of direct experience with tasks (Berry et al., 2013). Overall, studies show older adults with lower memory self- efficacy perform worse on memory tasks. Yet older adults with low memory self-efficacy compensate for poor memory performance by using people for assistance and compensatory strategies to aid in their memory performance (de Frias et al., 2003; Lachman & Agrigoroaei, 2012).
Age Differences in Memory Monitoring. Memory monitoring involves knowing what you are doing with your memory right now. The ability to monitor one’s memory does not appear to decline with age (Hertzog & Dunlosky, 2011). This is important, as memory mon- itoring may provide a basis for compensating for real age-related declines in episodic memory through the use of memory strategies. Older adults who are better at monitoring are more likely to use effective strategies (Hertzog, Price, & Dunlosky, 2012), and apply strate- gies learned in training to other, appropriate situations (Hertzog & Dunlosky, 2012).
Metamemory is important in understanding how people formulate predictions of how well they are likely to perform; monitoring and using data from
Freidman, 2012). They are based not only on mem- ory and performance per se but also on how we view ourselves in general, our theories about how memory works, what we remember from past evaluations, and our attributions and judgments of our effectiveness.
Aspects of Memory Self-Evaluations Researchers of memory self-evaluation have focused primarily on two types of awareness about memory. The first type involves knowledge about how memory works and what we believe to be true about it; this type of self-evaluation is referred to as metamemory. For instance, we may know recall is typically harder than recognition memory strategies are often helpful, and working memory is not limitless. We may also believe memory declines with age, appointments are easier to remember than names, and anxiety impairs perfor- mance. Metamemory is most often assessed with ques- tionnaires asking about these various facts and beliefs.
The second type of self-evaluation, called memory monitoring, refers to the awareness of what we are doing with our memory right now. We can be aware of the process of remembering in many ways. At times we know how we study, search for some particular fact, or keep track of time for an appointment. At other times we ask ourselves questions while doing a memory task. For example, when faced with having to remember an important appointment later in the day, we may con- sciously ask ourselves whether the steps we have taken (e.g., making a note in our smartphone) are sufficient.
Age Differences in Metamemory and Memory Monitoring
Researchers explored age differences in metamemory mainly by using questionnaires (see Castel et al., 2012; Tonković & Vranić, 2011). These questionnaires tap several dimensions of knowledge about memory and reflect the complexity memory itself. Older adults seem to know less than younger adults about the inter- nal workings of memory and its capacity, view mem- ory as less stable, expect memory will deteriorate with age, and perceive they have less direct control over memory (Blatt-Eisengart & Lachman, 2004; Hertzog & Dunlosky, 2011; Horhota, Lineweaver, Ositelu, Sum- mers, & Hertzog, 2012). Do these beliefs affect how well people actually remember information? Does what you believe about yourself matter?
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174 CHAPTER 6
in The Iliad was told for generations through the use of mnemonic strategies before it was finally written down. Self-help books teach readers how to improve their own memory have also been around for a long time (e.g., Grey, 1756). Interestingly, the old how-to books taught techniques virtually identical with those advocated in more contemporary books such as those generated by Harry Lorayne, who we encountered at the beginning of this chapter.
Training people how to remember information better, especially through the use of memory strategies, can be aimed at any adult. As you may have realized in our earlier discussion about memory strategies, most of the best strategies share several things in common. First, they require paying attention to the incoming information. Second, they rely on already-stored infor- mation to facilitate making new connections with the new material in semantic memory. Finally, in the pro- cess of encoding, strategies provide the basis for future retrieval cues. Additionally, putting training for mem- ory strategies in the context of healthy life styles tends to enhance the positive outcomes (Miller, Siddarth, Gaines, Parrish, Ercoli, Marx et al., 2012).
Memory aids or strategies can be organized into meaningful groups. Among the most useful of these classifications is Camp and colleagues’ (1993) E-I-E- I-O framework. The E-I-E-I-O framework combines two types of memory, explicit memory and implicit memory, with two types of memory aids; external aids and internal aids.
As discussed earlier, explicit memory involves the conscious and intentional recollection of information; remembering this definition on an exam is one exam- ple. Implicit memory involves effortless and uncon- scious recollection of information such as knowing stop signs are red octagons is usually not something people need to exert effort to remember when they see one on the road.
External aids are memory aids that rely on envi- ronmental resources, such as notebooks or calendars. Internal aids are memory aids that rely on mental pro- cesses, such as imagery. The Aha! or Oh! experience in the framework is the one that comes with suddenly remembering something. As you can see in Table 6.1 , the E-I-E-I-O framework helps organize how different types of memory can be combined with different kinds of memory aids to provide a broad range of interven- tion options to help people remember.
one’s performance may be more important for sub- sequent predictions on the same task. The good news is evidence suggests in older adulthood, the ability to monitor multiple aspects of memory functioning is relatively spared (Hertzog & Dunlosky, 2011).
Adult Development in Action How might you use self-evaluations of memory in your job as a director of a senior center?
6.5 Memory Training LEARNING OBJECTIVES
What are the major ways memory skills are trained? How effective are these methods?
After retirement, Alison and Charlie noticed they had trouble remembering things more than they used to. They worried that given their advanced age there was nothing they could do about it. However, one night they saw an advertisement on television suggesting we have control over our memory fitness. As fate would have it, the next day there was a flyer posted in their condomin- ium recreation room for a memory training class to help older adults overcome memory failures. They immedi- ately signed up.
Imagine you have problems remembering where you left your keys. Or suppose someone you love has gone through a comprehensive diagnostic process, and a memory problem was discovered. Can anything be done to help people remember? In most cases, the answer is yes. Fortunately for Alison and Charlie they learned of this. Researchers developed different types of memory training programs; many are effec- tive for healthy older adults, even for persons with severe memory impairments (Gross, Parisi, Spira, Kueider, Ko, Saczynski et al., 2012; Hunter, Ward, & Camp, 2012). In this section we examine the attempts at remediating memory problems and the individual differences affecting the success of these programs.
Training Memory Skills The notion memory can be improved through acquir- ing skills and practicing them is old, dating back to prehistory (Yates, 1966). For example, the story related
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ATTENTION AND MEMORY 175
interventions like this can help older adults maintain their independence. Nursing homes also use explicit- external interventions, such as bulletin boards with the date and weather conditions, to help residents keep in touch with current events.
Advocating the use of external aids in memory rehabilitation is becoming increasingly popular as well as extensively grounded in research. Camp, Zeisel, and Antenucci (2011) advocate external aids should be relied on alone or in combination with other tech- niques (e.g., Montessori methods) in working with Alzheimer’s patients. Research also indicates for exter- nal cues to be most effective, they should (1) be given close to the time action is required, (2) be active rather than passive, (3) be specific to the particular action, (4) be portable, (5) fit a wide range of situations, (6) store many cues for long periods, (7) be easy to use, and (8) not require a pen or pencil.
External-implicit combinations, more widely used with children, nevertheless have applicability with older adults in some situations. Many nursing homes use different color schemes to designate different wings or sections of the building. Because people process the color-coded aspects of the building automatically, the implicit nature of this external cue makes it ideal for people who may otherwise have difficulty learning and remembering new information.
Internal Memory Aids. Looking at Camp and col- leagues’ examples of internal memory aids may trig- ger some personal experiences. Many people use rote rehearsal in preparing for an examination (e.g., repeating Camp—E-I-E-I-O over and over), or use mental imag- ery in remembering the location of their car in a parking lot (we’re parked near the giraffe on the light post).
We can use Camp and colleagues’ approach to examine research on external and internal memory aids. In addition, we briefly review two alternatives, memory exercises and medications.
External Memory Aids. External memory aids are objects such as diaries, address books, calendars, notepads, microcomputers, and other devices com- monly used to support memory in everyday situa- tions like taking notes during a visit to the physician (McGuire, Morian, Codding, & Smyer, 2000; Watson & McKinstry, 2009). Some external aids involve actually using external device to store information (e.g., smart- phones or paper calendars), whereas others involve the use of external aids to cue action (e.g., setting a book out by the door so you won’t forget it).
In general, explicit-external interventions, espe- cially those involving smartphones or other computer- based devices, are the most frequently used, because they are easy to use, widely available, and work well with adults affected by a wide variety of physical or mental disorders (Bäckman, 2012; Thompson, Koor- enhof, & Kapur, 2012; Wallace & Morris, 2012). Many of the apps on a smartphone are aimed at relieving us of memory burden (e.g., contacts, calendars, maps). These explicit-external interventions have potential value for improving older adults’ cognitive perfor- mance in real-world settings.
The problem of remembering one’s complex medication schedule is best solved with an explicit- external intervention: a pillbox divided into compart- ments corresponding to days of the week and different times of the day. Research shows this type of pillbox is the easiest to load and results in the fewest errors, and works for people with mild cognitive impair- ment (Ownby, Hertzog, & Czaja, 2012). Memory
TYPE OF MEMORY TYPE OF MEMORY AID
External Internal
Explicit Appointment book Grocery list
Mental imagery Rote rehearsal
Implicit Color-coded maps Sandpaper letters
Spaced retrieval Conditioning
Table 6.1
The E-I-E-I-O model of memory helps categorize different types of memory aids
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176 CHAPTER 6
have produced only modest, short-term improvements with no long-term changes.
Most of the medications approved by the United States Food and Drug Administration work through neurotransmitters (see Chapter 2 ). Two groups of medications receiving most of the attention are cholin- esterase inhibitors (e.g., Aricept, Exelon). Side effects include nausea, vomiting, and diarrhea. A second group of medications are memantine, target glutamate, another neurotransmitter. The most common side effect of this medication is dizziness. Unfortunately, neither class of medications works well, especially as dementia worsens.
Many medications have side effects that can cause memory problems. Although alcohol is one widely known drug having this outcome, many over-the- counter and prescription medications can create symp- toms that mimic various types of memory problems, and can be quite severe if left unaddressed. Medica- tions commonly used to lower cholesterol (statins) can cause memory problems such as forgetfulness. Clearly, if one is taking medications and experiencing memory difficulties, a thorough analysis of whether the medica- tion is causing the side effect should be conducted.
Most research on memory training discussed ear- lier concerns of improving people’s use of these and other internal strategies that supply meaning and help organize incoming information. Classic examples of formal internal strategies include the method of loci (remembering items by mentally placing them in locations in a familiar environment), mental retrac- ing (thinking about all the places you may have left your keys), turning letters into numbers, and form- ing acronyms out of initial letters (such as NASA from N ational A eronautic and S pace A dministration). Most memory improvement courses train people to become proficient at using one of these internal strategies.
Getting proficient at explicit-internal memory strat- egies is hard work. As noted earlier, explicit strategies require effortful processing that is more taxing on older adults. Thus, explicit memory intervention would most likely work best with older adults who are least likely to suffer memory failures or for young adults. In fact, healthy older adults are less willing to use effortful inter- nal strategies. In addition, older adults with dementia are unlikely to benefit from these types of strategies (Camp et al., 2011). Thus, Camp argues older adults would ben- efit more from preserved implicit memory abilities.
One implicit-internal memory aid proven quite powerful is based on a technique called spaced retrieval. Camp and colleagues (Camp, 2005; Hunter et al., 2012; Bourgeois et al., 2003) relate even people with Alzheimer’s disease can learn new things with this technique. Spaced retrieval involves teaching persons with dementia or other serious cognitive impairment to remember new information by gradually increasing the time between retrieval attempts. This easy, almost magical technique has been used to teach names of staff members and other information, and it holds consid- erable potential for broad application. It is superior to other techniques (Haslam, Hodder, & Yates, 2011), and combining spaced retrieval with additional memory encoding aids helps even more (Kinsella et al., 2007).
Memory Drugs. Although considerable research has focused on the underlying neurological mechanisms in memory, little definitive information is available that can be easily translated into treatment approaches, though this is not for lack of trying. Many attempts at enhancing memory through the use of drugs that affect neurotransmitters have been made, but so far
Adult Development in Action As a nursing home administrator, how could you apply the principles of memory training to improve the quality of life of your residents?
6.6 Clinical Issues and Memory Testing LEARNING OBJECTIVES
What is the difference between normal and abnormal memory aging?
What are the connections between memory and physical and mental health?
How is memory affected by nutrition?
Latarra’s children are concerned. Latarra is 80 and is becoming more and more forgetful. With the scare of Alzheimer’s disease so salient in our society, they are con- cerned their mother is its next victim. What should they
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ATTENTION AND MEMORY 177
Normal versus Abnormal Memory Aging Many normative changes take place in memory as peo- ple grow old, such as those in working memory and episodic memory. Still, many aspects of memory func- tioning do not change, such as the ability to remem- ber the gist of a story. Increasingly forgetting names or what one needs at the supermarket, though annoy- ing, appears to be part of aging. However, some peo- ple experience far greater changes, such as forgetting where they live or their spouse’s name. Where is the line dividing normative memory changes from abnor- mal ones?
From a functional perspective, one way to distin- guish normal and abnormal changes is to ask whether the changes disrupt a person’s ability to perform daily living tasks. The normative changes we encountered in this chapter usually do not interfere with a person’s ability to function in everyday life. When problems appear, however, it would be appropriate to find out what is the matter. A person who repeatedly forgets to turn off the stove or how to get home is clearly expe- riencing changes affecting personal safety and inter- feres with his or her daily life. Such changes should be brought to the attention of a physician or psychologist.
As indicated in Chapter 2 , recent advances in neu- roscience, especially the study of brain–behavior rela- tions through neuroimaging, led to an explosion in our knowledge of specific diseases and brain changes that can create abnormal memory performance. Such brain-imaging techniques also allow researchers to find tumors, strokes, and other types of damage or disease that could account for poorer-than-expected memory performance.
Mapping the normative age-related changes in memory we have considered in this chapter is not easy, mainly because numerous parts of the brain are involved in processing information that eventually ends up in memory (Eichenbaum, 2012; Sasson, Doniger, Pasternak, Tarrasch, & Assaf, 2012). We know from Chapter 2 , the prefrontal cortex, parietal region, and hip- pocampus are involved in memory. There are also struc- tural changes in the white and gray matter that occur during learning that can also be measured (Zatorre, Fields, & Johansen-Berg, 2012). Local atrophy in these structures has been shown to be related to memory dec- rements in older adults (Kalpouzos et al., 2012).
do? A friend tells them memory decline is normal with aging. But to ease their concerns they make an appoint- ment for a clinical screening for their mother. This could reassure them it is only normal aging causing her forget- fulness, and not Alzheimer’s disease.
To this point we have been trying to understand the changes that occur in normal memory with aging. But what about situations where people have seri- ous memory problems that interfere with their daily lives? How do we tell the difference between normal and abnormal memory changes? These are two of the issues clinicians face. Latarra’s children face this criti- cal issue. Like Latarra’s children, clinicians are often confronted with relatives of clients who complain of serious memory difficulties. Clinicians must differ- entiate the individuals who have no real reason to be concerned from those with some sort of disease. What criteria should be used to make this distinction? What diagnostic tests would be appropriate to evaluate adults of various ages?
Unfortunately, there are no easy answers to these questions. First, as we have seen, the exact nature of normative changes in memory with aging is not yet understood completely. This means we have few stan- dards to compare for people who may have problems. Second, there are few comprehensive batteries of memory tests specifically designed to tap a wide vari- ety of memory functions (Mayes, 1995). Too often cli- nicians are left with hit-or-miss approaches and have little choice but to piece together their own assessment battery (Edelstein & Kalish, 1999).
Fortunately, the situation is changing. Since the mid-1980s researchers and clinicians began to work closely to devise better assessments (Mayes, 1995). This collaboration is producing results to help address the key questions in memory assessment: Has some- thing gone wrong with memory? Is the loss normal? What is the prognosis? What can be done to help the client compensate or recover?
In this section we consider the efforts being made to bridge the gap between laboratory and clinic. We begin with a brief look at the distinction between nor- mal and abnormal memory changes. Because abnormal memory changes could be the result of a psychologi- cal or physical condition, we consider links between memory and mental health. After that, we discuss how memory is affected by nutrition and drugs.
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178 CHAPTER 6
between incoming information and information already in memory (Warren Duff, Magnotta, Capizzano, Cas- sell, & Tranel, 2012). This usually makes it difficult for people to learn and remember new facts and events, typically resulting in serious disruption of everyday life. Damage to the medial temporal lobe usually results in severe impairment of long-term memory, but few, if any, other cognitive problems (Warren et al., 2012).
Occasionally, people temporarily experience a com- plete loss of memory and are disoriented in time, a con- dition known as temporary global amnesia or TGA . The condition is most common in middle-aged adults. Currently, the cause is unknown, and neuroimaging studies have not provided definitive evidence of spe- cific involvement of particular brain structures, nor is there consensus on the behavioral signs other than the memory problems, heightened anxiety, and depression (Hainselin, Quinette, Desgranges, Martinaud, De La Sayette, Hannequin et al., 2012). Persons who experi- ence TGA are often aware of their problem but under- estimate its severity. TGA has been associated with malfunctions of the valve in the jugular vein allow- ing blood to flows in the wrong direction (Baracchini, Tonello, Farina, Viaro, Atzori, Ballotta et al., 2012).
Memory impairment as a result of concussion, or traumatic brain injury, is the focus of a great deal of research, especially following concussion injuries received playing sports. Research clearly indicates there are a variety of negative effects on cognitive functioning following concussion, but adolescents are more likely to show longer-term effects than children or adults (Bail- largeon, Lassonde, Leclerc, & Ellemberg, 2012). Memory deficits observed immediately following concussion in adolescents injured playing sports could still be detected six months later. The effects of concussion and its relation to continuing to participate in sports is highly controver- sial, as discussed in the Current Controversies feature.
Some diseases, especially the dementias, are marked by massive changes in memory. For example, Alzheimer’s disease involves the progressive destruc- tion of memory beginning with recent memory and eventually including the most personal—self- identity. Wernicke-Korsakoff syndrome, often accompanies long-term alcoholism, and involves major loss of recent memory and sometimes a total inability to form new memories after a certain point in time.
The most important point to keep in mind is telling the difference between normal and abnormal memory aging, and in turn, between memory and other cogni- tive problems, is often difficult (Fisher, Plassman, Hee- ringa, & Langa, 2008). There is no magic number of times someone must forget something before getting concerned. Because serious memory problems can also be due to underlying mental or physical health prob- lems, these must be thoroughly checked out in conjunc- tion with obtaining a complete memory assessment. A good general rule, though, is this. Forgetting where you parked the car in a large parking lot is a typical memory problem. Forgetting that you drove is another matter.
Memory and Physical and Mental Health Several psychological disorders involve distorted thought processes that sometimes result in serious memory problems. The two disorders that are the main focus of research are depression and dementia; but other disorders, such as amnesia following a major seizure in epilepsy, head injury, or brain disease (e.g., stroke), are also important. We consider depression and dementia in detail in Chapter 10 .
Damage to the brain resulting from physical or mental health disorders can result in profound decre- ments in different types of memory. For example, severe seizures in epilepsy can result in damage to the hippo- campus and is heavily involved in creating associations
CURRENT CONTROVERSIES: CONCUSSIONS AND ATHLETES Traumatic brain injury (TBI), such as concussion, can hap- pen in just about any sport, as well as in combat injuries, exposure to explosions, automobile accidents, falls, or any other type of situation when one’s head is hit hard. In essence, the brain slams against the skull, resulting in
various levels of at least temporary damage and impair- ment. When you consider that between 2 and 4 million Americans are treated for mild TBI, with many more untreated, it is clear that TBI is a major concern.
Two situations brought TBI to the forefront: wars in Afghanistan and Iraq since 2001 and sports injuries. Esti- mates are about 30 % of the military troops deployed in Iraq and Afghanistan who have suffered a TBI have per- manent cognitive impairments in attention, memory, or
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ATTENTION AND MEMORY 179
self-awareness (Jagoda, 2012). Despite each state hav- ing legislation governing how soon athletes can return to playing after experiencing a concussion, there is little agreement on the diagnosis, treatment, and prognosis for patients.
There are several approaches to the diagnosis of concussion. In the United States, the American Con- gress of Rehabilitation Medicine established criteria in 1993: any loss of consciousness, loss of memory before or after the event, and feeling disoriented. The American Academy of Neurology has also devel- oped criteria for evaluating sports concussions, depending on whether there was loss of conscious- ness or amnesia. Globally, the Consensus Statement on Concussion in Sport, developed in Zurich in 2008, governs the decision-making process (McCrory, Meeu- wisse, Johnston, Dvorak, Aubry, Molloy et al., 2009). These criteria include (Jagoda, 2012) the definition of concussion: Concussion is defined as a complex patho- physiological process affecting the brain, induced by traumatic biomechanical forces. Several common fea- tures are:
Caused either by a direct blow to the head, face, neck, or elsewhere on the body with an “impul- sive” force transmitted to the head
Typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously
May result in neuropathological changes but the acute clinical symptoms largely reflect a func- tional disturbance rather than a structural injury
Results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follow a sequential course; it is impor- tant to note in a small percentage of cases, post- concussive symptoms may be prolonged
No abnormality on standard structural neuro- imaging
The difficulty with all of these criteria is determin- ing the seriousness of a TBI is often not easy. A signifi- cant percentage of people with a mild TBI based on the behavioral symptoms will show a significant lesion on a brain scan (Jagoda, 2012). Similarly, individuals such as Natasha Richardson, who died after hitting her head in a fall on a ski slope in 2009, showed few immediate
signs she was actually experiencing bleeding between her brain and her skull.
Ignoring TBIs, especially repeated ones, can be deadly. A brain autopsy following the suicide at age 50 of former NFL player Dave Duerson in 2011 revealed he suffered from chronic traumatic encephalopathy (CTE), a form of dementia caused by repeated head trauma. Duerson suffered 10 known concussions, and reported symptoms well after he retired from foot- ball. Other former players who died relatively young also may have had the disease. Researchers at the Boston University School of Medicine Center for the Study of Traumatic Encephalopathy reported that 14 of 15 brains for former NFL players they examined showed evidence of CTE (Smith, 2011).
Clearly, there is more awareness of the problems associated with repeated TBI. Whether sports, or at least certain sports involving physical contact, should now be considered dangerous remains to be seen. What is cer- tain, though, is the effects of repeated TBI last well into adulthood, and can cause serious cognitive impairment, and perhaps death, at a relatively early age.
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Memory and Nutrition Researchers and clinicians often overlook nutrition as a cause of memory failures in adulthood (King, 2012). Evidence points to several compounds in healthy
diets essential for well-functioning memory. Consid- erable research indicates flavonoids, found in green tea and blueberries, among other foods, may reverse age-related deficits in spatial memory (Rendeiro,
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180 CHAPTER 6
Guerreiro, Williams, & Spencer, 2012). Dietary iron intake in midlife has also been associated with better verbal memory, even after other potential explana- tions for the data were taken into account (Rickard, Chatfield, Powell, Stephen, & Richards, 2012). Finally, several vitamins, especially B vitamins 6 , 9 (folic acid), and 12 , have been associated with memory and other cognitive functions (de Jager, 2012).
These data indicate it is important to consider older adults’ diets when assessing their memory per- formance. What may appear to be serious decrements
Adult Development in Action As a family member with older relatives living in your home, how can you help them maintain good memory?
in functioning may, in fact, be induced by poor nutri- tion or specific medications. Too often, researchers and clinicians fail to inquire about eating habits. Adequate assessment is essential to avoid diagnostic errors.
Social Policy Implications With the graying of America we will see more and more older adults with memory-related problems. Thus, one important implication of this demographic trend is to meet the needs of this growing issue. The number of outreach memory and aging centers is growing in the United States. Such centers attract individuals with any level of memory impairment. These outreach programs connect to local communi- ties and provide educational and referral opportuni- ties along with skill development and training and resource development. The centers are important because they can bridge the gap between research, education, and patient care. Many of these centers
are interdisciplinary in nature and thus have the benefit of collaborations with researchers in aging, neurologists, neuropsychologists, nurses, and phar- macists. They serve as catalysts to facilitate interac- tions among local networks of researchers and other applied centers such as chapters of the Alzheimer’s Disease Association to enhance education and information dissemination. Thus, the implications of memory and aging research are becoming more important in our society. With the aging of the baby boomers, the social implications of understanding the memory competencies of our newest older gen- eration have only begun to become apparent.
Summary 6.1 Overview of Information Processing
What are the primary aspects of the information- processing model?
The information-processing model is based on a computer metaphor and assumes an active partici- pant, both quantitative and qualitative aspects of performance, and processing of information trans- formed through a series of systems.
Sensory memory is the first level of processing incoming information from the environment. Sen- sory memory has a large capacity, but information only lasts there a short time.
What are the basic components of attention? From a functional perspective, attention consists of
processing different aspects of stimuli.
How does speed of processing relate to cognitive aging?
Speed of processing refers to how quickly and efficiently the early steps in information process- ing are performed. In general, older adults are slower.
What types of processing resources relate to attention and memory?
Some researchers claim older adults have fewer processing resources than younger adults. How- ever, this conclusion is suspect because processing resources is ill defined.
Processing resources refers to the amount of atten- tion one has to apply to a particular situation.
Older adults have more difficulty filtering out or inhibiting irrelevant information (called inhibitory loss) than younger adults, but this may also have a beneficial effect under certain circumstances.
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ATTENTION AND MEMORY 181
What age differences have been found in encoding versus retrieval?
Age-related decrements in encoding may be due to decrements in rehearsal within working mem- ory and being slower at making connections with incoming information. Older adults do not spon- taneously organize incoming information as well as younger adults, but they can use organizational helps when told to do so. However, the benefits of this approach are short-lived. Although older adults tend not to use optimal encoding strate- gies, this does not account for poor memory per- formance.
Age-related decline in retrieval is related to both poorer encoding to some degree as well as failure to use retrieval strategies. Older adults also have more tip-of-the-tongue experiences than younger adults.
6.3 Memory in Context
What age differences are there in prospective memory?
Age differences are less likely on event-based pro- spective memory tasks than on time-based pro- spective memory tasks. How accurately prospective memory tasks are performed depends on the time of day. Processing speed may help explain these age differences.
How does autobiographical memory change across adulthood?
Some aspects of autobiographical memory remain intact for many years whereas other aspects do not. More memories are present from young adulthood than later in life. Verification of autobiographical memories is often difficult.
Older adults have fewer flashbulb memories and their impact is restricted to particular points in the life span.
How does source memory and processing misinformation change across adulthood?
The ability to remember the source of a familiar event or whether the event was imagined or expe- rienced declines with age.
Older adults are more susceptible to false memo- ries in that they remember items or events that did not occur under specific conditions of plausibility and are more likely to believe false information as true.
Divided attention assesses attentional resources and involves doing more than one task that demands attention. Age differences in divided attention depend on the degree of task complexity and practice.
What are automatic and effortful processing? Automatic processing places minimal demands on
attentional capacity whereas effortful processing requires all of the available attentional capacity. There are relatively no age differences in the for- mer and pronounced age differences in the latter.
6.2 Memory Processes
What is working memory? What age differences have been found in working memory?
Working memory refers to the processes and struc- tures involved in holding information in mind and simultaneously using that information, sometimes in conjunction with incoming information, to solve a problem, make a decision, or learn. Information is kept active through rehearsal.
In general, working memory capacity and rehearsal decline with age, although the extent of the decline is still in doubt. There is some evidence age differences in working memory are not universal.
How does implicit and explicit memory differ across age?
Implicit memory involves retrieval of information without conscious or intentional recollection.
Explicit memory is intentional and conscious remembering of information learned and remem- bered at a specific point in time.
Older adults are generally better at implicit mem- ory tasks than explicit memory tasks.
Within long-term memory, how does episodic and semantic memory performance differ across age?
Long-term memory refers to the ability to remem- ber extensive amounts of information from a few seconds to a few hours to decades.
In episodic memory, age-related decrements are typically found on recall tests but not on recogni- tion tests. Older adults tend not to use memory strategies spontaneously as often or as well as younger adults.
Semantic memory concerns learning and remem- bering the meaning of words and concepts not tied to specific occurrences of events in time. Fewer age differences are found in semantic memory.
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182 CHAPTER 6
6.6 Clinical Issues
What is the difference between normal and abnormal memory aging?
Whether memory changes affect daily function- ing is one way to separate normal from abnormal aging. Brain-imaging techniques allow localization of problems with more precision.
Some diseases are marked by severe memory impairments. However, in many cases, telling the difference between normal changes and those associated with disease or other abnormal events is difficult.
Different areas of the brain control different aspects of memory.
What is the connection between memory and physical and mental health?
Dementia (such as Alzheimer’s disease) and severe depression both involve memory impairment.
Temporary global amnesia, more common in mid- dle age than in younger or older adulthood, may be related to blood flow in the brain.
Traumatic brain injury (TBI) can have serious conse- quences, as seen in the long-term potential dam- age from repeated concussions.
How is memory affected by nutrition? Flavonoids, iron, and B vitamins have all been
shown to be related to memory functioning.
REVIEW QUESTIONS 6.1 Information Processing and Attention
What is working memory? What is inhibition loss? What age differences have been found? What role do these processes play in understanding age dif- ferences in memory?
What is episodic memory? What is semantic mem- ory? How are they tested? What patterns of age differences have been found? What happens to the use of memory strategies with age?
What is sensory memory? How do processing speed and processing resources
affect older adults’ information processing? In what way do older adults have difficulty filtering
out information? How do automatic and effortful processing contrib-
ute to age differences in information processing?
What are some factors that help preserve memory as we grow older?
Exercise, multilingualism, use of semantic memory, and avoiding the application of memory stereo- types are all factors that can enhance memory in older adults and delay cognitive decline.
6.4 Self-Evaluations of Memory Abilities
What are the major types of memory self-evaluations? There are two general categories of memory self-
evaluations. Metamemory refers to knowledge about how memory works and what one believes to be true about it. Memory monitoring refers to the awareness of what we are doing with our memory right now.
What age differences have been found in metamemory and memory monitoring?
Metamemory is typically assessed with ques- tionnaires. Older adults seem to know less than younger adults about the workings of memory and its capacity, view memory as less stable, believe their memory will decline with age, and feel they have little control over these changes. Memory self- efficacy is an important predictor of performance in several settings.
The ability to monitor one’s performance on mem- ory tasks does not usually decline with age. Memory monitoring may provide a basis for compensating for actual performance declines.
6.5 Memory Training
What are the major ways memory skills are trained? How effective are these methods?
The E-I-E-I-O framework, based on explicit-implicit aspects of memory and external-internal types of strategies, is a useful way to organize memory training.
Older adults can learn new internal memory strate- gies but, like all adults, usually abandon them over time.
External-explicit strategies (such as lists and calen- dars) are common, but internal-implicit strategies are effective even with persons who have Alzheimer’s disease.
Use of memory enhancing drugs does not work over the long run.
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ATTENTION AND MEMORY 183
What physical and mental health conditions involve significant memory problems?
What effect does nutrition have on memory?
INTEGRATING CONCEPTS IN DEVELOPMENT Based on material in Chapter 2 on cognitive neuro-
science and the material in this chapter, what are the major factors involved in understanding age- related differences in memory?
What aspects of neurological functioning would be important to consider in designing memory train- ing programs?
How could you design a good set of observations for family members to help them tell whether a rel- ative’s memory failures were normal or abnormal?
Based on information in Chapters 3 and 4 , what health promotion principles would help keep memory functioning better?
How would you design an informational brochure for older adults to maximize their ability to remem- ber it?
KEY TERMS autobiographical memory Remembering information and events from your own life.
automatic processing Processes that are fast, reliable, and insensitive to increased cognitive demands.
cognitive reserve Factors that provide flexibil- ity in responding and adapting to changes in the environment.
divided attention The ability to pay attention and successfully perform more than one task at a time.
effortful processing It requires all of the available attentional capacity when processing information.
encoding The process of getting information into the memory system.
episodic memory The general class of memory having to do with the conscious recollection of information from a specific event or point in time.
explicit memory The conscious and intentional recol- lection of information.
external aids Memory aids that rely on environmental resources.
false memory When one remembers items or events that did not occur.
Why are attentional resources important to our understanding of age differences in memory?
6.2 Memory Processes What are working memory processes and how do
they differ with increasing age? What is the difference between implicit and explicit
memory? How do they change with age? Why are there age differences in episodic but not
semantic memory? What are the relative contributions of encoding
and retrieval in understanding age differences in memory?
6.3 Memory in Context What types of prospective memory have been
distinguished? What age differences are there in prospective memory?
What is autobiographical memory and how does it differ with age?
How do source memory and processing of misinfor- mation change with age?
What are factors preventing decline in memory functioning? How do they work?
6.4 Self-Evaluations of Memory Abilities What major types of self-evaluations have been
described? What age differences are there in metamemory
and memory self-efficacy? What age differences have been found in memory
monitoring?
6.5 Memory Training What is the E-I-E-I-O framework? How does it help
organize memory training programs? How much do older adults benefit from each of the
major types of memory training programs? What kinds of memory interventions work over
time?
6.6 Clinical Issues What criteria are used to determine the difference
between normal and abnormal changes in a per- son’s memory?
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184 CHAPTER 6
retrieval The process of getting information back out of memory.
semantic memory Learning and remembering the meaning of words and concepts that are not tied to specific occurrences of events in time.
sensory memory A very brief and almost identical representation of the stimuli that exists in the observ- able environment.
source memory The ability to remember the source of a familiar event as well as the ability to determine if an event was imagined or actually experienced.
speed of processing How quickly and efficiently the early steps in information processing are completed.
storage The manner in which information is represented and kept in memory.
strategies Various techniques that make learning or remembering easier and that increase the efficiency of storage.
temporary global amnesia or TGA Temporary experience of a complete memory loss and disorienta- tion in time.
working memory Refers to the processes and structures involved in holding information in mind and simultaneously using that information, some- times in conjunction with incoming information, to solve a problem, make a decision, or learn new information.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
flashbulb memories Memories for personally traumatic or unexpected events.
implicit memory The effortless and unconscious recollection of information.
information-processing model The study of how people take in stimuli from their environment and transform them into memories; the approach is based on a computer metaphor.
internal aids Memory aids that rely on mental processes.
long-term memory The aspects of memory involved in remembering rather extensive amounts of information over relatively long periods of time.
memory monitoring The awareness of what we are doing in memory right now.
memory self-efficacy The belief in one’s ability to perform a specific memory task.
metamemory Memory about how memory works and what one believes to be true about it.
processing resources The amount of attention one has to apply to a particular situation.
prospective memory Process involving remembering to remember something in the future.
recall Process of remembering information without the help of hints or cues.
recognition Process of remembering information by selecting previously learned information from among several items.
rehearsal Process by which information is held in working memory, either by repeating items over and over or by making meaningful connections between the information in working memory and information.
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Intelligence, Reasoning, Creativity, And Wisdom
7.1 DEFINING INTELLIGENCE Intelligence in Everyday Life • The Big Picture: A Life-Span View • Research Approaches to Intelligence • Discovering Development: How Do People Show Intelligence?
7.2 DEVELOPMENTAL TRENDS IN PSYCHOMETRIC INTELLIGENCE The Measurement of Intelligence • Primary and Secondary Mental Abilities • Fluid and Crystallized Intelligence • Neuroscience Research and Intelligence in Young and Middle Adulthood • Moderators of Intellectual Change • Current Controversies: Problems in Detecting Education and Life Style Effects on Intellectual Functioning • Modifying Primary Abilities
7.3 QUALITATIVE DIFFERENCES IN ADULTS’ THINKING Piaget’s Theory • Going beyond Formal Operations: Thinking in Adulthood • Integrating Emotion and Logic
7.4 EVERYDAY REASONING AND PROBLEM SOLVING Decision Making • How Do We Know?: Age Differences in Information Search and Decision Making • Problem Solving • Expertise • Creativity and Wisdom
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 7
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186 CHAPTER 7
The Dalai Lama, Spiritual Leader Of The Tibetan People, Was The Recipient Of The 1989 Nobel Peace Prize, And Is Recognized As A Leader In Buddhist Philosophy, Human Rights, And Global Environmental Problems. He reached this stature as a simple Buddhist monk, and claims he is “no more, no less.” To the world, the Dalai Lama is recognized for his great wisdom and insight into the human condition. A sample of this wisdom is in his plea for “a new way of thinking . . . for responsible living and acting. If we maintain obsolete values and beliefs, a fragmented consciousness and a self-centered spirit, we will continue to hold to outdated goals and behaviors. Such an attitude by a large number of people would block the entire transition to an interdependent yet peaceful and cooperative global society.” He also states as a Buddhist monk, he tries to develop compassion within, not simply as religious practice, but at a human level. To facilitate this he “sometimes finds it helpful to imagine himself standing as a single individual on one side, facing a huge gathering of all other human beings on the other side. Then he asks himself, ‘Whose interests are more impor- tant?’ To him it is quite clear however important he feels he is, he is just one individual while others are infinite in number and importance.”
The Dalai Lama drives home the point that wisdom has long been associated with age. Sur- prisingly, psychologists only recently became inter- ested in wisdom, perhaps because they were busy studying a related topic—intelligence. Another reason for not researching wisdom was the wide- spread belief it would be a waste of time. At one time, researchers and theorists were convinced all intellectual abilities inevitably declined as people aged, because of biological deterioration. For instance, Wechsler (1958) wrote “nearly all stud- ies have shown that most human abilities decline progressively after reaching a peak somewhere between ages 18 and 25 ” ( 135 ) .
In the decades since Wechsler stated this pes- simistic view, many things changed. Researchers
discovered intellectual development is an extremely complex process. We cannot give a simple yes or no answer to the question “Does intelligence decline with age?” and we continue to move farther away, rather than closer to, a simple answer.
Controversy raged for decades. Consider- ing methodological comparisons between cross- sectional and longitudinal studies, Baltes and Schaie (1974) concluded “general intellectual decline is largely a myth” ( p. 35 ) . Botwinick (1977) countered with “decline in intellectual ability is clearly a part of the aging picture” ( p. 580 ) .
Who is right? Where do we stand now? Does intelligence decline, or is that a myth? Does wisdom come with age? Answering these ques- tions will be our goal in this chapter. Such widely divergent conclusions about age-related changes in intelligence reflect different sets of assumptions about the nature of intelligence that are then translated into different theoretical and method- ological approaches. We examine three avenues of research on intelligence and age: psychometric approach, life-span approach, and the cognitive- structural approach. Along the way we look at some attempts to modify intellectual abilities through training programs, but first we need to consider what intelligence is.
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 187
7.1 Defining Intelligence LEARNING OBJECTIVES
How do people define intelligence in everyday life?
What are the major components of the life-span approach?
What are the major research approaches for studying intelligence?
When Toni graduated from high school she decided to start her own pet-sitting business. She started small, but ultimately cornered the market in her city. She lives a comfortable and wealthy lifestyle. After high school, her classmate Stacey went to college and majored in math. She pursued her doctorate and now lives a comfortable and modest lifestyle as a university professor. In compar- ing Toni and Stacey on intellectual ability, who would come out on top?
In terms of intelligence, the distinction between Toni and Stacey’s success points to an important ques- tion to ask: What do we mean by intelligence? Is intelli- gence being able to learn new things quickly? Knowing a great deal of information? The ability to adapt to new situations or create new things or ideas? Or is intelli- gence the ability to make the most of what we have and to enjoy life? Intelligence encompasses all these abili- ties and more as we see in the different pathways Toni and Stacey took. It is all in the sense that people who stand out on these dimensions are often considered smart, or intelligent. It is more than just these abili- ties because intelligence also involves the qualitative aspects of thinking style, or how one approaches and conceptualizes problems.
Intelligence in Everyday Life Robert Sternberg and his colleagues agree intelli- gence involves more than just a particular fixed set of characteristics (Sternberg, Jarvin, & Grigorenko, 2010). His approach is based on a list of behaviors that laypeople at a train station, supermarket, or col- lege library reported to be distinctly characteristic of exceptionally intelligent, academically intelligent, everyday intelligent, or unintelligent people. This list of behaviors was given to experts in the field of intelligence and to a new set of laypeople. They were
asked to rate either how distinctively characteristic each behavior was, or how important each behavior was in defining the four types of intelligence: excep- tional, academic, everyday, or unintelligent people. Ratings were analyzed separately for the experts and the laypeople.
There is extremely high agreement between experts and laypeople on ratings of the importance of particular behaviors in defining intelligence. The two groups agreed intelligence consisted of three major clusters of related abilities: problem-solving ability, verbal ability, and social competence. Problem-solving ability consists of behaviors such as reasoning logi- cally, identifying connections among ideas, seeing all aspects of a problem, and making good decisions. Ver- bal ability comprises such things as speaking articu- lately, reading with high comprehension, and having a good vocabulary. Social competence includes behav- iors such as accepting others for what they are, admit- ting mistakes, displaying interest in the world at large, and being on time for appointments.
In a classic study, Berg and Sternberg (1992) wanted to know how these conceptions of intelli- gence differed across the adult life span. To find out, people aged 22 to 85 were asked to rate 55 behaviors they viewed as characteristic of exceptionally intel- ligent 30 - , 50 - , or 70 - year-olds. Behaviors such as motivation, intellectual effort, and reading were said to be important indicators of intelligence for people of all ages. Other behaviors were specific to particu- lar points in the life span. For example, a 30 - year-old planning for the future and being open-minded were listed most often. The intelligent 50 - and 70 - year- olds were described as acting responsibly, adjusting to life situations, being verbally fluent, and displaying wisdom.
The Big Picture: A Life-Span View One thing is clear about the ways people view intelligence—everyone has an idea of what intelligence is, and everyone considers it a complex construct. In the big picture, then, intelligence consists of many different skills. Theories of intelligence, therefore, are multidimensional ; that is, they specify many domains of intellectual abilities. Although people disagree on the number of dimensions, they agree no single generic
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188 CHAPTER 7
type of intelligence is responsible for all the mental activities we perform.
Baltes and colleagues (1993; 2006) take a broad view of intellectual development. The life-span con- cepts discussed in Chapter 1 including multidirec- tionality, plasticity, and interindividual variability play an important role in this conceptualization of intellectual change. Overall, this perspective asserts intellectual decline may be seen with age but stability and growth in mental functioning also can be seen across adulthood. The life-span perspective empha- sizes the role of intelligence in human adaptation and daily activity.
The first concept, multidirectionality , refers to the distinct patterns of change in abilities over the life span, with these patterns differing for different abili- ties. For example, developmental functions for spe- cific abilities differ, meaning the directional change in intelligence depends on the skills in question. As you will see later on, everyday knowledge accumulates over time and thus increases with age. However, basic cognitive mechanisms show more declines, especially into older age.
The term plasticity refers to the range of function- ing within an individual and the conditions under which a person’s abilities can be modified within a specific age range. Plasticity implies what may appear to be declines in some skills may in part represent a lack of practice in using them. Current studies examining brain plasticity and behavior find experience alters the brain across the life span (see Chapter 2 ). For example, Reuter-Lorenz (2002; Park & Reuter-Lorenz, 2009; Reuter-Lorenz & Mikels, 2006) found older and young adults show dif- ferent activation patterns in the brain when they per- form cognitive tasks. As we saw in Chapter 2 , older adults activate areas in the brain that compensate for decline in their performance, resulting in better per- formance than would otherwise be the case. In other words, older adults activate new areas in the brain to compensate for decline in other areas. Finally, the research on training cognitive abilities described later in this chapter supports this view because older adults who show decline in cognitive functioning can be trained to perform at a higher level.
The last concept, interindividual variability , acknowledges adults differ in the direction of their
intellectual development . Schaie’s (2008) sequential research indicates within a given cohort or genera- tion, some people show longitudinal decline in specific abilities whereas other people show stability of func- tioning, and display improvements in those same abili- ties. Consequently, a single representation of typical or average changes with age may not really represent how the various individuals in a group function.
Using these four concepts of multidimension- ality, plasticity, multidirectionality, and interindi- vidual variability, Baltes and his colleagues proposed the dual-component model of intellectual function- ing. Two interrelated types of developmental pro- cesses are postulated. The first component, termed the mechanics of intelligence , concerns the neuro- physiological architecture of the mind (Baltes et al., 2006). This architecture provides the bases for cog- nitive abilities, including basic forms of thinking associated with information processing and prob- lem solving such as reasoning, spatial orientation, or perceptual speed. Intellectual change in this first component is greatest during childhood and ado- lescence, as we acquire the requisite skills to handle complex cognitive tasks such as those encountered in school.
The second component, pragmatic intelligence , concerns acquired bodies of knowledge available from and embedded within culture. In other words, it includes everyday cognitive performance and human adaptation. Such abilities include verbal knowledge, wisdom, and practical problem solving. Pragmatic intellectual growth dominates adulthood.
These different trajectories of development are illustrated in Figure 7.1 . As the figure suggests, dif- ferent weightings of the forces of intelligence lead to specific predictions regarding the developmen- tal pathway they take across the adult life span. If biological-genetic forces are considered to govern the mechanics more, a downward trajectory appears with age. However, if the pragmatics of intelligence is considered to be governed more by environmental- cultural factors, an upward trajectory is maintained across the adult life span.
This broad view of intellectual development in adulthood provides the background for asking more specific questions about particular aspects of
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 189
intelligence. As we will see, three primary research approaches have emerged.
Research Approaches to Intelligence Sternberg’s and Baltes’ work point out many different skills are involved in intelligence, depending on one’s point of view. Interestingly, the behaviors listed by Sternberg’s participants and the organizational struc- ture provided by Baltes fit nicely with the more formal attempts at defining intelligence we encounter later in this chapter. Researchers have studied these skills from many perspectives, depending on their theoretical ori- entation. For example, some investigators approach these skills from a factor analysis approach and study them as separate pieces that can be added together to form intelligence. Others take a more holistic view and think of intelligence as a way or mode of thinking. These various theoretical orientations result in differ- ent means of studying intelligence.
Some investigators have concentrated on measur- ing intelligence as performance on standardized tests; this view represents the psychometric approach . For example, the problem-solving and verbal abilities in Sternberg and colleagues’ study would be assessed by tests specifically designed to assess these skills. These
tests focus on getting correct answers and tend to give less emphasis on the thought processes used to arrive at them.
Other researchers focus on information-processing mechanisms reviewed in Chapter 6 . This approach aims at a detailed analysis of aging-associated changes in components of cognitive mechanisms and their interactions.
Finally, a number of researchers focused their efforts on reconceptualizing the meaning and measure- ment of intelligence by taking a cognitive-structural approach. In the cognitive-structural approach researchers have been more concerned with the ways people conceptualize and solve problems than with scores on tests. Such approaches to intelligence empha- size developmental changes in the modes and styles of thinking.
In this chapter, we consider these approaches and the research they stimulated. We discover each approach has its merits and whether age-related changes in intelligence are found depends on how intelligence is defined and measured. Before you con- tinue, complete the exercise in the Discovering Devel- opment feature. The information you uncover will be useful as you read the rest of the chapter.
ca. 25
Pragmatics (crystallized)
Mechanics (fluid)
Intelligence as cultural knowledge
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Figure 7.1 Life-span conceptualization of the mechanics and pragmatics of intelligence. The mechanics of intelligence correspond to fluid intelligence and the pragmatics to crystallized intelligence, as described later. Source: Baltes, P. B. (1993). The aging mind: Potential and limits. The Gerontologist, 33, 580–594. The figure is Figure 1, p. 582.
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190 CHAPTER 7
7.2 Developmental Trends in Psychometric Intelligence LEARNING OBJECTIVES
What is intelligence in adulthood? What are primary and secondary mental abilities?
How do they change? What are fluid and crystallized intelligence? How
do they change? How has neuroscience research furthered our
understanding of intelligence in adulthood?
Ashley, a 35 -year-old woman recently laid off from her job as an administrative assistant, slides into her seat on her first day of classes at the community college. She is clearly nervous. “I’m worried I won’t be able to com- pete with these younger students, that I may not be smart enough,” she sighs. “Guess we’ll find out soon enough, though, huh?”
Many returning adult students like Ashley worry they may not be “smart enough” to keep up with 18 - or 19 - year-olds. Are these fears realistic? We see how the answer to this question depends on the types of intel- lectual skills being used.
As seen earlier, people naturally view intelligence as consisting of many components. One traditional way to measure intelligence, then, is to focus on indi- viduals’ performances on various tests of these compo- nent intellectual abilities and how these performances are interrelated. This approach to intelligence has a long history; the ancient Chinese and Greeks used this method to select people for certain jobs, such as mas- ter horseman (Doyle, 1974; DuBois, 1968). Tests also served as the basis for Alfred Binet’s (1903) pioneering work in developing standardized intelligence tests, as well as many modern theories of intelligence.
Because of this long history of research in psycho- metric intelligence, we probably know more about this area than any other area in cognitive aging except for episodic memory. Yet this still provided no sense of closure as to how intelligence changes with age. There is substantial agreement on descriptions of change in different intellectual abilities (as we discuss later) and agreement on the methodological issues needing to be addressed when studying intellectual change.
However, there is little consensus on the proper interpretation of the data. For example, what does it mean that changes in intellectual abilities are related to increasing age? Remember in Chapter 1 we noted age does not cause change, that age is related to intel- lectual abilities is not the same thing as “aging” per se. As we shall see, age-related intellectual change is also related to important variables such as health, activity level, and educational achievements. It is in these areas that much of the controversy is still brewing.
The Measurement of Intelligence Because the psychometric approach focuses on the interrelationships among intellectual abilities, the
DISCOVERING DEVELOPMENT: HOW DO PEOPLE SHOW INTELLIGENCE? Earlier in this section, we encountered Sternberg and colleagues’ research on people’s implicit theories of intelligence. However, that study only examined broad categories of behavior that could be consid- ered intelligent. Moreover, it was not conducted in such a way as to permit comparisons with research- based approaches to intelligence.
You and your classmates could address these shortcomings in the following way. Ask adults of dif- ferent ages what they think constitutes intelligent behavior, much the same as Sternberg and colleagues did. However, be careful to make sure people are spe- cific about the abilities they nominate. In addition, ask them about what makes adults’ thinking differ- ent from adolescents’ thinking and whether they believe there might be different stages of adults’ thinking. Again, try to get your respondents to be as specific as possible.
Collate all the data from the class. Look for com- mon themes in specific abilities, as well as in the qual- itative aspects of thinking. As you read the rest of the chapter, see to what extent your data parallels that from more formal investigations.
Adult Development in Action If you were responsible for revising social policy regarding aging (say, criteria for living independently in the community), how would you approach that problem from the different perspectives of defining intelligence?
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 191
major goal has long been to describe the ways these rela- tionships are organized (Sternberg, 1985). This organi- zation of interrelated intellectual abilities is termed the structure of intelligence . The most common way to describe the structure of intelligence is to picture it as a five-level hierarchy (Cunningham, 1987).
Each higher level of this hierarchy represents an attempt to organize components of the level below in a smaller number of groups. The lowest level consists of individual test questions—the specific items people answer on an intelligence test. These items or ques- tions can be organized into tests at the second level.
The third level, primary mental abilities, reflects interrelationships among performances on intelligence tests. The interrelationships uncovered among the pri- mary mental abilities produce the secondary mental abilities at the fourth level. Finally, general intelligence at the top refers to the interrelationships among the third-order abilities.
Keep in mind each time we move up the hierar- chy we move away from people’s actual performance. Each level above the first represents a theoretical description of how things fit together. Thus, there are no tests of primary abilities per se; primary abilities represent theoretical relationships among tests, that in turn represent theoretical relationships among actual performance.
So exactly how do researchers construct this theo- retical hierarchy? The structure of intelligence is uncov- ered through sophisticated statistical detective work using factor analysis. First, researchers obtain people’s performances on many types of problems. Second, the results are examined to determine whether perfor- mance on one type of problem, such as filling in miss- ing letters in a word, predicts performance on another type of problem, like unscrambling letters to form a word. If the performance on one test is highly related to the performance on another, the abilities measured by the two tests are interrelated and are called a factor .
Most psychometric theorists believe intelligence consists of several factors. However, we should note although factor analysis is a sophisticated statistical technique, it is not an exact technique. Thus, estimates of the exact number of factors vary from a few to over 100 . Most researchers and theorists believe the number to be relatively small. We examine two factors: primary and secondary mental abilities.
Primary and Secondary Mental Abilities Since the 1930s, researchers agreed intellectual abilities can be studied as groups of related skills (such as mem- ory or spatial ability) organized into hypothetical con- structs called primary mental abilities. In turn, related groups of primary mental abilities can be clustered into a half dozen or so broader skills termed secondary mental abilities.
Roughly 25 primary mental abilities have been identified (Horn, 1982). Because it is difficult to study all of them, researchers focused on five representative ones:
Number : the basic skills underlying our math- ematical reasoning
Word fluency : how easily we produce verbal descriptions of things
Verbal meaning : our vocabulary ability Inductive reasoning : our ability to extrapolate from
particular facts to general concepts Spatial orientation : our ability to reason in the
three-dimensional world
Even with a relatively small number of primary mental abilities, it is still hard to discuss intelligence
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192 CHAPTER 7
by focusing on separate abilities. As a result, theories of intelligence emphasize clusters of related primary mental abilities as a framework for describing the structure of intelligence. Because they are one step removed from primary mental abilities, secondary mental abilities are not measured directly. This can be seen in Figure 7.2 for the secondary mental ability crystallized intelligence, one of two secondary mental abilities we will consider next: fluid and crystallized intelligence.
Fluid and Crystallized Intelligence As noted earlier, primary abilities are themselves orga- nized into clusters of secondary mental abilities. A summary of the major secondary mental abilities is presented in Table 7.1. Two secondary mental abilities have received a great deal of attention in adult devel- opmental research: fluid intelligence and crystallized intelligence (Horn, 1982).
Fluid intelligence consists of the abilities that make you a flexible and adaptive thinker, allow you to make inferences, and enable you to understand the relations among concepts . It includes the abilities you need to understand and respond to any situation, but especially new ones: inductive reasoning, integration, abstract thinking, and the like (Horn, 1982). An example of a question that taps fluid abilities is the following: What letter comes next in the series d f i m r x e ? 1
Crystallized intelligence is the knowledge you have acquired through life experience and educa- tion in a particular culture . Crystallized intelligence includes your breadth of knowledge, comprehension of communication, judgment, and sophistication with information (Horn, 1982). Many popular television game shows (such as Jeopardy and Wheel of Fortune ) are based on contestants’ accumulated crystallized intelligence.
Developmentally, fluid and crystallized intelli- gence follow two different paths, as you can see in Fig- ure 7.3 . Notice, fluid intelligence declines throughout adulthood, whereas crystallized intelligence improves. Although we do not yet fully understand why fluid intelligence declines, it may be related to underlying changes in the brain (Horn & Hofer, 1992). In contrast, the increase in crystallized intelligence (at least until late life) indicates people continue adding knowledge every day.
What do these different developmental trends imply? First, they indicate that—although it continues through adulthood—learning becomes more difficult with age.
Primary mental ability (e.g., verbal comprehension)
Vocabulary Similarities Social
translations Social situations
Secondary mental ability (e.g., crystallized intelligence)
Primary mental ability (e.g., experiential evaluation)
Figure 7.2 Secondary mental abilities reflect several primary mental abilities and their respective measurements. This figure shows those relations regarding crystallized intelligence. © 2015 Cengage Learning
1 The next letter is m . The rule is to increase the difference between adja- cent letters in the series by one each time and use a continuous circle of the alphabet for counting. Thus, f is two letters from d, i is three letters from f , and e is seven letters from x .
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 193
Table 7.1
Descriptions of Major Secondary Mental Abilities Crystallized intelligence (Gc) This form of intelligence is indicated by a very large number of performances indicating breadth of knowledge and experience, sophistication, comprehen- sion of communications, judgment, understanding of conventions, and reasonable thinking. The factor that provides evidence of Gc is defined by primary abilities such as verbal comprehension, concept formation, logical reasoning, and general reasoning. Tests used to measure the ability include vocabulary (What is a word near in meaning to temerity ?), esoteric analo- gies (Socrates is to Aristotle as Sophocles is to _____?), remote associations (What word is associated with bathtub, prizefighting , and wedding ?), and judgment (Determine why a foreman is not getting the best results from workers). As measured, the factor is a fallible representation of the extent to which a person has incorporated, through the systematic influences of acculturation, the knowledge and sophistication that constitutes the intelligence of a culture.
Fluid intelligence (Gf) The broad set of abilities of this intelligence includes those of seeing relationships between stimulus pat- terns, drawing inferences from relationships, and comprehending implications. The primary abilities that best represent the factor, as identified in completed research, include induction, figural flexibility, integra- tion, and, cooperatively with Gc, logical reasoning and general reasoning. Tasks that measure the factor include letter series (What letter comes next in the series d f i m r x e?), matrices (Discern the relationships between elements of 3-by-3 matrices), and topology (From among a set of figures in which circles, squares, and triangles overlap in different ways, select a figure that will enable one to put a dot within a circle and a square but outside a triangle). The factor is a fal- lible representation of such fundamental features of mature human intelligence as reasoning, abstracting, and problem solving. In Gf these features are not imparted through the systematic influences of accul- turation but instead are obtained through learning that is unique to an individual or is in other ways not organized by the culture.
Visual organization (Gv) This dimension is indicated by primary mental abilities such as visualization, spatial orientation, speed of clo- sure, and flexibility of closure, measured by tests such as gestalt closure (Identify a figure in which parts have been omitted), form board (Show how cutout parts
Source: Horn, J. L. (1982). The aging of human abilities. In B. B. Wolman (Ed.), Handbook of Developmental Psychology (pp. 847–870). Englewood Cliffs, NJ: Prentice Hall. Reprinted with permission.
fit together to depict a particular figure), and embed- ded figures (Find a geometric figure within a set of intersecting lines). To distinguish this factor from Gf, it is important that relationships between visual patterns be clearly manifest so performances reflect primarily fluency in perception of these patterns, not reasoning in inferring the process.
Auditory organization (Ga) This factor has been identified on the basis of several studies in which primary mental abilities of temporal tracking, auditory cognition of relations, and speech perception under distraction of distortion were first defined among other primary abilities and then found to indicate a broad dimension at the second order. Tasks that measure Ga include repeated tones (Identify the first occurrence of a tone when it occurs several times), tonal series (Indicate which tone comes next in an orderly series of tones), and cafeteria noise (Iden- tify a word amid a din of surrounding noise). Like Gv, this ability is best indicated when the relationships among stimuli are not such that one needs to reason for understanding but instead are such that one can fluently perceive patterns among the stimuli.
Short-term acquisition and retrieval This ability comprises processes of becoming aware and processes of retaining information long enough to do something with it. Almost all tasks that involve short-term memory have variance in this factor. Span memory, associative memory, and meaningful memory are primary abilities that define the factor, but mea- sures of primary and secondary memory can also be used to indicate the dimension.
Long-term storage and retrieval Formerly this dimension was regarded as a broad fac- tor among fluency tasks, such as those of the primary abilities called associational fluency, expressional flu- ency, and object flexibility. In recent work, however, these performances have been found to align with others indicating facility in storing information and retrieving information that was acquired in the distant past. It seems, therefore, that the dimension mainly represents processes for forming encoding associations for long-term storage and using these associations, or forming new ones, at the time of retrieval. These associations are not so much correct as they are pos- sible and useful; to associate teakettle with mother is not to arrive at a truth so much as it is to regard both concepts as sharing common attributes (e.g., warmth).
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Second, intellectual development varies a great deal from one set of skills to another. Whereas indi- vidual differences in fluid intelligence remain rela- tively uniform over time, individual differences in crystallized intelligence increase with age, largely because maintaining crystallized intelligence depends on being in situations that require its use (Horn, 1982; Horn & Hofer, 1992). For example, few adults get much practice in solving complex letter series tasks like the one on page 192 , but because people improve their vocabulary skills by reading and vary consider- ably in how much they read, differences are likely to emerge.
Neuroscience Research and Intelligence in Young and Middle Adulthood
As you might suspect from Chapters 2 and 6 , con- siderable research shows specific areas in the brain are associated with intellectual abilities, and develop- mental changes in these areas are related to changes in performance. On the basis of 37 studies using vari- ous brain imaging techniques, Jung and Haier (2007) originally proposed the Parieto-Frontal Integration Theory that we encountered in Chapter 2 . Remember
the Parieto-Frontal Integration Theory (P-FIT) pro- poses intelligence comes from a distributed and inte- grated network of neurons in the parietal and frontal lobes of the brain. (The parietal lobe is at the top of the head; the frontal lobe is behind the forehead.) In gen- eral, P-FIT accounts for individual differences in intel- ligence as having their origins in individual differences in brain structure and function.
The P-FIT model has been tested in several stud- ies. Results indicate support for the theory when mea- sures of fluid, crystallized, and spatial intelligence are related to brain structures assessed in young adults through neuroimaging (Brancucci, 2012; Shih & Jung, 2009). It is also clear performance on measures of spe- cific abilities is likely related to specific combinations of brain structures (Haier et al., 2010).
A second theory of intelligence based on neurosci- ence evidence is based on how efficiently the brain works (Brancucci, 2012). The neural efficiency hypothesis , states intelligent people process information more effi- ciently, showing weaker neural activations in a smaller number of areas than less intelligent people. Research evidence is mounting that this idea holds merit, and with greater intelligence does come demonstrably
14–17 18–20 21–28 29–39 40–61
Age
Low
High
Pe rf
o rm
an ce
Tests of crystallized intelligence
Tests of fluid intelligence
General IQ tests
Figure 7.3 Performances on tests used to define fluid, crystallized, and general intelligence, as a function of age. Source: Horn, J. L. (1970). Organization of data on life-span development of human abilities. In L. R. Goulet & P. B. Baltes (Eds.), Life-span Develop- ment Psychology: Research and Theory (p. 463). Copyright © 1970 by Academic Press, reproduced by permission of the publisher.
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 195
increased efficiency in neural processing (e.g., Lipp, Benedek, Fink, Koschutnig, Reishofer, Bergner et al., 2012). However, how this neural efficiency develops is not yet known, nor are its developmental pathways understood.
It is clear neuroscience and related research on intelligence will continue to provide many insights into the bases for both the development of fluid and crystallized intelligence as well as understanding indi- vidual differences in each (Nisbett et al., 2012).
Finally, intellectual abilities have long been known to correlate with mortality in late life, but recent evi- dence increasingly shows this relation also holds in middle age based on research in Sweden (Batty et al., 2009). and Britain (Sabia et al., 2010).
Moderators of Intellectual Change Based on the research we considered thus far, two dif- ferent developmental trends emerge: we see gains in experience-based processes but losses in information- processing abilities. The continued growth in some areas is viewed as a product of lifelong learning. The losses are viewed as an inevitable result of the decline of physiological processes with age.
A number of researchers, though, emphasize individual differences in the rate of change in intellec- tual aging (Baltes et al., 2006; MacDonald et al., 2004; Schaie, 2008). These researchers do not deny that some adults show intellectual decline. Based on large indi- vidual differences in intellectual performance over time, they simply suggest these decrements may not happen to everyone to the same extent. They argue many reasons besides age explain performance dif- ferences. In this section, we explore some of the social and physiological factors proposed as modifiers of intellectual development. These include cohort dif- ferences, education level, social variables, personality, health and lifestyle, and relevancy and appropriateness of tasks.
Cohort Differences. Do the differences in intellec- tual performance obtained in some situations reflect true age-related change or mainly cohort, or genera- tional, differences? This question gets right to the heart of the debate over interpreting developmental research on intelligence. On one hand, dozens of cross-sectional studies document significant differences in intellectual
performance with age. On the other hand, several longitudinal investigations show either no decrement or even an increase in performance (Hertzog, Dixon et al., 2003; Schaie, 2005, 2008, 2011; Zelinski, Kenni- son, Watts, & Lewis, 2009).
The way to resolve the discrepancy between the two approaches involves comparing data collected over long periods of time from several samples and analyzed simultaneously in both cross-sectional and longitudinal designs as discussed in Chapter 1 . When this is done, the results indicate part of the apparent decline with age in performance on intelligence tests is because of generational differences rather than age differences (Schaie, 2005, 2011; see also the How Do We Know? feature earlier in this chapter). These trends reflect better education opportunities, healthier life- styles, better nutrition, and improved health care.
The complex pattern of cohort differences indi- cates interpreting data from cross-sectional stud- ies is difficult. Recall from Chapter 1 cross-sectional studies confound age and cohort; and because there are both age- and cohort-related changes in intellec- tual abilities, drawing any meaningful conclusions is nearly impossible. Schaie (2005, 2008, 2011) argues the trends indicate a leveling off of cohort differences, that may come to a halt in the early part of the 21 st century. This conclusion is supported by a study of 531 adult parent– offspring pairs indicating generational (cohort) improvements were becoming smaller for more recently born pairs (Schaie et al., 1992).
Information Processing. A number of research- ers suggest general processing constraints that occur with aging (discussed in Chapter 6 ) may help identify mechanisms underlying decline in fluid intelligence abilities with age (Baltes et al., 2006; Zimprich & Martin, 2002, 2009). For example, evidence suggests perceptual speed accounts for much of the age-related decline in both fluid and crystallized mental abili- ties. Similarly, working memory decline with increas- ing age accounts for poor performance on the part of older adults when the tasks involve coordinating both new incoming information and stored informa- tion such as those found in the fluid and/or mechanic component of intelligence. Finally, evidence suggests the inability to inhibit actions and thoughts or to avoid interference typically found in older adults may
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also account for efficient functioning in fluid and/or mechanic abilities.
Social and Life Style Variables. Numerous social and life style variables have been identified as impor- tant correlates of intellectual functioning. Think for a minute about the kind of job you currently have or would like to get. What kind of intellectual skills does it demand? What similarities or differences are there between your chosen job (e.g., school counselor) and a different one (say, accountant)? An interesting line of research concerns how the differences in cognitive skills needed in different occupations makes a differ- ence in intellectual development (Bosma, van Boxtel, Ponds, Houx, & Jolles, 2003; de Grip, Bosma, Willems, & van Boxtel, 2008). To the extent a job requires you to use certain cognitive abilities a great deal, you may be less likely to show declines in them as you age.
Other social demographic variables implicated in slower rates of intellectual decline include a higher socioeconomic status, exposure to stimulating envi- ronments, the utilization of cultural and educational resources throughout adulthood, and not feeling lonely (Schaie, 2008). For example, research examin- ing loneliness suggests it is associated with more rapid
cognitive decline (Wilson, Krueger, Arnold, Schnei- der, Kelly, Barnes et al., 2007) and for having a mental health problem later in life (Coyle & Dugan, 2012).
Finally, although research suggests education and life style factors are a predictor of intellectual func- tioning, it is still a matter of debate whether it helps slow cognitive change in late life (Hertzog et al., 2009; Zahodne, Glymour, Sparks, Bontempo, Dixon, Mac- Donald et al., 2011). We examine this debate in the Current Controversies feature.
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CURRENT CONTROVERSIES: PROBLEMS IN DETECTING EDUCATION AND LIFE STYLE EFFECTS ON INTELLECTUAL FUNCTIONING The fact that having more formal education is positively correlated to one’s intelligence is well established in the research literature. Similarly, there is evidence certain life style factors, such as cognitive engagement and social engagement, are also correlated with intellectual functioning (Small, Dixon, McArdle, & Grimm, 2012).
Education is an important predictor of both fluid and crystallized abilities (Constantinidou, Christodoulou, & Prokopiou, 2012). In some studies, it also predicts sur- vivorship, in some cases to age 100 or beyond (Martin, Hagberg, & Poon, 2012).
These findings led some researchers to speculate education may provide protection against abnormal cognitive aging, such as Alzheimer’s disease, perhaps by creating extra cognitive reserve or by changing the brain to have thicker cortex. The evidence is mixed. There is little evidence of structural brain changes, such
as cortical thickening, with higher levels of education (Pillai, McEvoy, Hagler, Holland, Dale, Salmon et al., 2012). However, other research documents increased white matter volume in some brain regions (Foubert- Samier, Catheline, Amieva, Dilharreguy, Helmer, Allard et al., 2012). There is also growing evidence higher levels of education results in lower rates of dementia, but par- adoxically, once cognitive decline begins and is notice- able it proceeds more rapidly and there is evidence of greater damage in the brain (Meng & D’Arcy, 2012).
Research examining cognitive engagement in adulthood shows that reductions in such engagement are correlated with declines in verbal speed, episodic memory, and semantic memory (Small et al., 2012). In turn, cognitive decline is associated with decreases in social engagement. What’s not clear though is what comes first. Is it the case that the memory declines are the result of lower cognitive engagement, or is it the reverse (that memory declines are the reason for decreases in cognitive engagement)? We cannot tell from the research, because the nature of the research design, correlational, does not permit such determina- tions to be made (see Chapter 1 ).
People in cognitively demanding jobs may be less likely to show noticeable declines in cognitive functioning with increasing age.
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 197
So how do we reconcile these data? On one hand, education is related to increased performance on intel- ligence tests, and becoming less cognitively active is related to performance declines. One would expect education and cognitive activity to protect people against cognitive decline. But that’s not what happens in the long run. What’s going on?
One possibility is that education per se is not what is at work. Rather, there are two other possibilities. Because education is correlated with a healthier life style on average, perhaps it is the latter that is responsi- ble for the data. For example, research showing shorter telomere length (see Chapter 3 ), an indicator of biolog- ical aging, is related to low educational levels that in
turn relate to less healthy life style (Kingma, de Jonge, van der Harst, Ormel, & Rosmalen, 2012). Also, because education does produce some level of cognitive reserve, it is likely the amount of cognitive decline necessary for others to notice is greater than it is for people with less education. That would explain why, once cognitive decline in highly educated people becomes noticeable, it appears to proceed rapidly.
Overall, we need more carefully conducted research to understand the role played by education and life style and their relation to intelligence and cognitive changes with age. Only when we separate education from its related variables (e.g., health) will we under- stand its actual role.
Personality. Several aspects of personality have been proposed as important for understanding intellectual change. Similar to research we examined in Chapter 6 on memory, one of these aspects concerns self-efficacy (Hayslip & Cooper, 2012). Older adults perceive what they do to help maintain their intellectual abilities can make a difference. Specifically, high initial levels of fluid abilities and a high sense of internal control led to positive changes in people’s perceptions of their abili- ties; low initial levels led to decreases in perceptions of ability and behavior (Lachman & Andreoletti, 2006).
Neuroticism and chronic psychological distress have been implicated in rapid cognitive decline (Wilson, Arnold et al., 2006; Wilson, Bennett et al., 2005). This makes sense given neuroticism is strongly associated with frequency of negative emotions. Nega- tive emotions and psychological distress go hand-in- hand. Furthermore, neurobiological research suggests chronic psychological distress may cause deteriorative changes in the limbic system of the brain that regulates emotion and cognition (Dwivedi et al., 2003; Webster et al., 2002). These deteriorative changes could cause cognitive impairment. However, this area is still in its infancy and further research is needed.
On a more upbeat note, positive beliefs and atti- tudes also have important indirect effects on cogni- tive enrichment. This indirect effect is reflected in the influence of these beliefs and attitudes on desir- able behaviors such as exercise and mental stimula- tion known to be associated with enrichment effects on intelligence (Hertzog et al., 2009). Research indi- cates people with flexible attitudes at midlife tend to experience less decline in intellectual competence than
people who are more rigid in middle age (Lachman, 2004; Willis & Boron, 2008).
Health. The most obvious relationship between health and intelligence concerns the functioning of the brain itself. We noted in Chapter 2 several normative changes in brain structure with age affect functioning. We also noted in Chapter 6 brain injuries, nutrition, and other factors can also affect functioning. Diseases such as dementia wreak havoc in the brain, and others, such as cardiovascular disease, can have serious negative effects.
Cardiovascular disease and its implications for intellectual functioning have been studied extensively. These diseases are linked to a pattern of cognitive impairment that looks like what is typically observed in “normal” cognitive aging. Some researchers sug- gest the effects of age on intelligence and cognition are related at least in part to vascular disease that selec- tively affects the prefrontal brain (Spiro & Brady, 2008).
Finally, we noted in Chapters 3 and 6 physical exercise has considerable benefit. In this context, exer- cise helps maintain cognitive fitness as well as slow down cognitive decline once it has begun (Amoyal & Fallon, 2012). This alone should be enough reason to get up and get moving!
Modifying Primary Abilities As you have seen, older adults do not perform as well on tests of some primary abilities as younger adults, even after taking the moderators of performance into account (Schaie, 2005). In considering these results, investigators began asking whether there was a way to slow down or even reverse the declines. There has been
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much research examining the effects of lifestyle, health, and personality, among other variables, on intelligence.
Pursuing this issue further, we ask a number of relevant questions regarding training. Are the age- related differences remaining after cohort and other effects are removed permanent, or might these dif- ferences be reduced or even eliminated if older adults are given appropriate training? Can we modify adults’ intelligence? This again addresses the important issue of plasticity in intellectual functioning, one of the life- span tenets discussed in Chapter 1 .
The most common training research focuses on those intellectual abilities that constitute primary men- tal abilities, especially those clustered into fluid intelli- gence. These are the intellectual abilities most likely to decline with age. Middle-aged and older adults can be successfully taught to increase their speed of process- ing, and this training transfers to tasks not included in the training sessions (Simpson, Camfield, Pipingas, Macpherson, & Stough, 2012).
Two large-scale projects examined training of pri- mary abilities over extended periods of time. These projects adopt the view that aging in healthy adults has great potential for cognitive growth (Lövdén et al., 2012), with the research largely being conducted within the Selective Optimization with Compensation (SOC) framework described in Chapter 1 . Let’s see what researchers discovered in Project ACTIVE.
Project ACTIVE. Sherry Willis has revolutionized our understanding of how far researchers can go to inves- tigate the impact of training primary mental abilities. She designed a longitudinal research project named Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) to provide answers to key questions about whether the age-related changes observed in intel- ligence research were inevitable or could be modified through training (Unverzagt, Smith, Rebok, Marsiske, Morris, Jones et al., 2009; Willis & Schaie, 2009).
Begun in the mid-1990s, the ACTIVE study was a multicenter, randomized, controlled clinical research project that investigates the long-term effectiveness of cognitive training on enhancing mental abilities (mem- ory, reasoning, and attention) and preserving instru- mental activities of daily living (managing finances, taking medication, using the telephone, and driving) in older adults. Six centers across the eastern United
States enrolled nearly 3000 people initially. Participants underwent detailed assessments of mental and functional ability on multiple occasions over several years of follow- up. The design of Project ACTIVE is shown in Figure 7.4 .
The ACTIVE project findings show cognitive training interventions improved mental abilities and daily functioning in older independent living adults (e.g., Ball, Berch, Helmers, Jobe, Leveck, Marsiske et al., 2002). ACTIVE also showed positive effects of cognitive training at 5 years post-intervention for basic mental abilities, health-related quality of life, and improved ability to perform instrumental activities of daily living (IADL) (Unverzagt et al., 2009).
There is an important caveat, though. A subgroup analysis through 2 years of follow-up suggested partic- ipants who showed mild cognitive impairment (MCI) did not benefit from memory training; interestingly though, they did benefit to the same degree as cogni- tively normal participants from training in reasoning and speed of processing. This finding suggests MCI may interfere with a person’s ability to benefit from some, but not all forms of cognitive enhancement.
Additional findings from Project ACTIVE indicate cognitive training aimed initially at improving specific primary mental abilities, such as speed of processing or reasoning, can also have positive effects on partici- pants’ sense of control over one’s life (Wolinsky, Vander Weg, Martin, Unverzagt, Willis, Marsiske et al., 2010).
The results from Project ACTIVE allow us to con- clude declines in fluid abilities may be reversible. Per- haps the best news is the training effects are relatively enduring. Depending on the ability trained and the training method, effects last at least between two and five years (Ball et al., 2002; Willis, Tennstedt, Marsiske, Ball, Elias, Koepke et al., 2006).
What can we conclude from these findings? First, there is strong evidence in the normal course of devel- opment, no one is too old to benefit from training and training reduces the rates of decline for those fluid abili- ties examined. Second, transfer of training occurs, but evidence is lacking that it occurs across a wide range of materials unless training involves executive function- ing and working memory, when the effects generalize to many different tasks (Basak, Boot, Voss, & Kramer, 2008; Dahlin, Stigsdotter, Larsson, Bäckman, & Nyberg., 2008). Finally, training gains are durable and last up to several years (Ball et al., 2002; Willis et al., 2006).
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 199
What is the role of both emotion and cognition in cognitive maturity?
Eddie, a student at a local university, thought the test he had just taken in his math course was unfair because the instructors simply marked the answers to complex problems right or wrong. He complained he deserved partial credit for knowing how to set up the problem and being able to figure out some of the steps.
Although Eddie did not know it, his argument par- allels one in the intelligence literature—the debate on whether we should pay attention mainly to whether an answer is right or wrong or to how the person reasons the problem through. The psychometric approach we considered earlier does not focus on the thinking pro- cesses underlying intelligence; rather, psychometrics
Figure 7.4 Experts in any field handle tasks in those fields differently than novices. Source: Unverzagt, F. W., Smith, D. M., Rebok, G. W., Marsiske, M., Morris, J. N., Jones, R. et al. (2009). The Indiana Alzheimer Disease Center’s Symposium on Mild Cognitive Impairment. Cogni- tive training in older adults: Lessons from the ACTIVE Study. Current Alzheimer Research, 6, 375–383. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2729785/figure/F1/
ACTIVE Conceptual Model
Individual Differences
• Cognitive ability
• Motor ability
• Sensory ability
• Personality
• Disease
• Demographics
• Genetics
Memory Training
Everyday Problem Solving
IADL and ADL Function
Everyday Speed
Health Service
Utilization
Mobility
Health Related
Qualtiy of Life
Reasoning Training
Speed Training
Attentional Processing
Speed
Reasoning
Memory
Proximal Outcomes
Primary Outcomes
Randomized Intervention
Secondary Outcomes
Adult Development in Aging If you were a director of a human resources depart- ment, how would the research on intelligence across adulthood influence your decisions about employee training programs?
7.3 Qualitative Differences In Adults’ Thinking LEARNING OBJECTIVES
What are the main points in Piaget’s theory of cognitive development?
What evidence is there for continued cognitive development beyond formal operations?
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concentrates on interrelationships among answers to test questions. In contrast, cognitive-structural approaches focus on the ways in which people think; whether a par- ticular answer is right or wrong is not important.
We will consider two theories that represent cognitive-structural approaches. First, we exam- ine Piaget’s theory as a foundation for this approach. Second, we explore the discussions concerning pos- sible extensions of it, post-formal theory. Both these approaches postulate intellectual changes are mainly qualitative, even though they differ on many points.
Piaget’s Theory According to Piaget (1970, 1980), intellectual devel- opment is adaptation through activity. We create the ways our knowledge is organized and, ultimately, how we think. Piaget believed development of intelligence stems from the emergence of increasingly complex cognitive structures. He organized his ideas into a theory of cognitive development that changed the way psychologists conceptualize intellectual development.
Basic Concepts. For Piaget, thought is governed by the principles of adaptation and organization. Adapta- tion is the process of adjusting thinking to the environ- ment. Just as animals living in a forest feed differently from the way animals living in a desert feed, how we think changes from one developmental context to another. Adaptation occurs through organization; that is how the organism is put together. Each component part has its own specialized function that is coordi- nated into the whole. In Piaget’s theory, the organiza- tion of thought is reflected in cognitive structures that change over the life span. Cognitive structures deter- mine how we think. It is the change in cognitive struc- tures, the change in the fundamental ways we think, Piaget tried to describe.
What processes underlie intellectual adaptation? Piaget defined two: assimilation and accommodation. Assimilation is the use of currently available knowledge to make sense out of incoming information. It is the appli- cation of cognitive structures to the world of experi- ence that makes the world understandable. A child who only knows the word dog may use it for every animal she encounters. So, when the child sees a cat and calls it a dog, she is using available knowledge, the word dog , to make sense out of the world—in this case the cat
walking across the living room. The process of assimi- lation sometimes leads to considerable distortion of incoming information, because we may have to force-fit it into our knowledge base. This is apparent in our ten- dency to forget information about a person that violates a stereotype.
Accommodation. involves changing one’s thought to make it a better approximation of the world of experi- ence. The child in our example who thought cats were dogs eventually learns cats are cats. When this hap- pens, she accommodated her knowledge to incorpo- rate a new category of animal.
The processes of assimilation and accommoda- tion serve to link the structure of thought to observable behavior. Piaget believed most changes during devel- opment involved cognitive structures. His research led him to conclude there were four structures (i.e., four stages) in the development of mature thought: senso- rimotor, preoperational, concrete operational, and for- mal operational. We consider the major characteristics of each stage briefly. Because we are most interested in Piaget’s description of adult thought, we emphasize that.
Sensorimotor Period. In this first stage of cognitive development, intelligence is seen in infants’ actions. Babies and infants gain knowledge by using their sen- sory and motor skills, beginning with basic reflexes (sucking and grasping) and eventually moving to pur- poseful, planned sequences of behavior (such as look- ing for a hidden toy). The most important thing infants learn during the sensorimotor period is that objects continue to exist even when they are out of sight; this ability is called object permanence.
Preoperational Period. Young children’s thinking is best described as egocentric. This means young chil- dren believe all people and all inanimate objects expe- rience the world just as they do. Young children believe dolls feel pain. Although young children can some- times reason through situations, their thinking is not based on logic. A young child may believe his father’s shaving causes the tap water to be turned on, because the two events always happen together.
Concrete Operational Period. Logical reasoning eme- rges in the concrete operational period. Children become capable of classifying objects into groups, such
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 201
as fruits or vegetables, based on a logical principle; men- tally reversing a series of events; realizing when changes occur in one perceptual dimension and they are com- pensated for in another, no net change occurs (termed conservation); and understanding the concept of tran- sitivity (for instance, if A > B and B > C , then A > C ). However, children are still unable to deal with abstract concepts such as love; to children love is a set of concrete actions and not an ill-defined abstract concept.
Formal Operational Period. For Piaget, the acquisi- tion of formal operational thought during adolescence marks the end of cognitive development. Because he argues formal operational thinking characterizes adult thought, we will consider this level in some detail. Piaget and other commentators (e.g., Lemieux, 2012) agree on four aspects of formal operational thought: (1) It takes a hypothesis-testing approach (termed hypothetico-deductive) to problem solving; (2) think- ing is done in one framework at a time; (3) the goal is to arrive at one correct solution; and (4) it is uncon- strained by reality.
Piaget describes the essence of formal operational thought as a way of conceiving abstract concepts and thinking about them in a systematic, step-by-step way. Formal operational thought is governed by a general- ized logical structure that provides solutions to problems people have never seen and may never encounter. Hypo- thetico-deductive thought is similar to using the scien- tific method; it involves forming a hypothesis and test- ing it until the hypothesis is either confirmed or rejected. Just as scientists are systematic in testing experimental hypotheses, formal operational thinking allows people to approach problem solving in a logical, methodical way.
Consider the situation when your car breaks down. When you take it for repairs, the mechanic forms hypoth- eses about what may be wrong based on a description of the trouble. The mechanic then begins to test each hypothesis systematically. The compression of each cyl- inder may be checked, one cylinder at a time. This ability to hold other factors constant while testing a particular component is one of the hallmarks of formal operational thought. By isolating potential causes of the problem, the mechanic efficiently arrives at a correct solution.
When we use hypothetico-deductive thought, we do so to arrive at one unambiguous solution to the prob- lem. Formal operational thought is aimed at resolving
ambiguity; one and only one answer is the goal. When more than one solution occurs, there is a feeling of uneasiness and people begin a search for clarification. This situation can be observed in high school classes when students press their teacher to identify the right theory (from among several equally good ones) or the right way to view a social issue (such as abortion). Moreover, when people arrive at an answer, they are quite certain about it because it was arrived at through the use of logic. When answers are checked, the same logic and assumptions are typically used, that some- times means the same mistake is made several times in a row. For example, a person may repeat a simple subtraction error time after time when trying to figure out why his or her checkbook failed to balance.
Formal operational thinking knows no constraints (Piaget, 1970, 1980). It can be applied just as easily to real or imaginary situations. It is not bound by the lim- its of reality (Labouvie-Vief, 1980). Whether one can implement a solution is irrelevant; what matters is one can think about it. This is how people arrive at solutions to disarmament, for example, such as getting rid of all nuclear warheads tomorrow. To the formal operational thinker, that this solution is logistically impossible is no excuse. The lack of reality constraints is not all bad, however. Reasoning from a “Why not?” perspective may lead to the discovery of completely new ways to approach a problem or the invention of new solutions.
One serious problem for Piaget’s theory is many adults apparently do not attain formal operations. Piaget (1972) himself admitted formal operations were probably not universal but tended to appear only in those areas that individuals were highly trained or spe- cialized. This inspired a number of researchers to look beyond formal operations in determining pathways of adult cognitive development.
Going Beyond Formal Operations: Thinking In Adulthood
Suppose you are faced with the following dilemma: You are a member of your college’s or university’s
student judicial board and are currently hearing a case involving plagiarism. The student handbook states pla- giarism is a serious offense resulting in expulsion. The student accused of plagiarizing a paper admits copying from Wikipedia but says she has never been told she needed to use a formal citation and quotation marks.
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202 CHAPTER 7
Do you vote to expel the student? When this and similar problems are presented to
older adolescents and young adults, interesting dif- ferences emerge. Adolescents tend to approach the problem in formal-operational terms and point out the student handbook is clear and the student ignored it, concluding the student should be expelled. Formal- operational thinkers are certain such solutions are right because they are based on their own experience and are logically driven.
But many adults are reluctant to draw conclusions based on the limited information in the problem, espe- cially when the problem can be interpreted in different ways (Sinnott, 1998). They point out there is much about the student we don’t know: Has she ever been taught the proper procedure for using sources? Was the fac- ulty member clear about what plagiarism is? For adults, the problem is more ambiguous. Adults may eventually decide the student is (or is not) expelled, but they do so only after considering aspects of the situation that go well beyond the information given in the problem.
Based on numerous investigations, researchers concluded this different type of thinking represents a qualitative change beyond formal operations (Kitch- ener, King, & DeLuca, 2006; Lemieux, 2012; Sinnott, 2009). Postformal thought is characterized by recogni- tion that truth (the correct answer) may vary from situa- tion to situation, solutions must be realistic to be reason- able, ambiguity and contradiction are the rule rather than the exception, and emotion and subjective factors usually play a role in thinking . In general, the research evidence indicates post formal thinking has its origins in young adulthood (Kitchener et al., 2006; Sinnott, 2009).
Several research-based descriptions of the devel- opment of thinking in adulthood have been offered. One of the best is the description of the development of reflective judgment , a way adults reason through dilem- mas involving current affairs, religion, science, personal relationships, and the like . Based on decades of longitu- dinal and cross-sectional research, King and Kitchener (2002; Kitchener et al., 2006) refined descriptions and identified a systematic progression of reflective judg- ment in young adulthood. A summary of these stages is shown in Table 7.2 .
The first three stages in the model represent prere- flective thought. People in these stages typically do not acknowledge and may not even perceive that knowl- edge is uncertain. Consequently, they do not under- stand some problems exist when there is not a clear and absolutely correct answer. A student pressuring her instructor for the “right” theory to explain human development reflects this stage. She is also likely to hold firm positions on controversial issues and does so without acknowledging other people’s ability to reach a different (but nevertheless equally logical) position.
About halfway through the developmental pro- gression, students think differently. In Stages 4 and 5, students are likely to say nothing can be known for certain and to change their conclusions based on the situation and the evidence. At this point, students argue knowledge is quite subjective. They are also less persua- sive with their positions on controversial issues: “Each person is entitled to his or her own view; I cannot force my opinions on anyone else.” Kitchener and King refer to thinking in these stages as “quasi-reflective” thinking.
As students continue their development into Stages 6 and 7, they begin to show true reflective judgment, understanding people construct knowledge using evi- dence and argument after careful analysis of the prob- lem or situation. They once again hold firm convictions but reach them only after careful consideration of sev- eral points of view. They also realize they must continu- ally reevaluate their beliefs in view of new evidence.
Even though people are able to think at complex levels, do they? Not usually (King & Kitchener, 2004). Why? Mostly because the environment does not pro- vide the supports necessary for using one’s highest- level thinking, especially for issues concerning knowl- edge and experience you already have. People may not always purchase the product with the least impact
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 203
on the environment, such as a fully electric car, even though philosophically they are strong environmental- ists, because recharging stations are currently not widely available. However, if pushed and if given the necessary supports (e.g., easily available charging stations), people demonstrate a level of thinking and performance far higher than they typically show on a daily basis.
Absolutist, Relativistic, and Dialectical Thinking. A growth in reflective judgment is not the only aspect of post-formal thought researchers examined. Kramer, Kahlbaugh, and Goldston (1992; see also Kallio, 2011) identified three distinct styles of thinking: absolutist, relativistic, and dialectical. Absolutist thinking involves firmly believing there is only one correct solution to problems and personal experience provides truth. Adolescents and young adults typically think this way. Relativistic thinking involves realizing there are many sides to any issue and the right answer depends on the circumstances. Young and early middle-aged adults often think this way. One potential danger is relativistic thinking can lead to cynicism or an “I’ll do my thing, and you do yours” approach to life. Because relativistic thinkers reason things out on a case-by-case basis, they are not likely to be strongly committed to any one posi- tion. The final step, dialectical thinking, clears up this
problem. Dialectical thinkers see the merits in the dif- ferent viewpoints but synthesize them into a workable solution. This synthesis often produces strong com- mitment and a definite plan of action.
Since Kramer et al.’s proposal, other researchers extended the notion of dialectical thinking to connect it to wisdom (Kross & Grossmann, 2012), coping flexi- bility (Cheng, 2009), and the ability to deal with a wide array of everyday problems effectively (Kallio, 2011).
Reflective judgment and dialectical thinking have much in common (Kallio, 2011). The key to postfor- mal thought is the ability to think integratively, to pull together various lines of thought into one integrated whole. That gives adults the ability to understand dif- ferent points of view and less likely to think from only one ideological perspective. One aspect of this integra- tion involves bringing together logic and emotion.
Integrating Emotion and Logic In addition to an increased understanding there is more than one “right” answer, adult thinking is charac- terized by the integration of emotion with logic (Jain & Labouvie-Vief, 2010; Labouvie-Vief, 2006; Labouvie- Vief, Grühn, & Studer, 2010). As they mature, adults tend to make decisions and analyze problems not so
Table 7.2
Description of the Stages of Reflective Judgment
Prereflective Reasoning (Stages 1–3): Belief that “knowledge is gained through the word of an authority figure or through firsthand observation, rather than, for example, through the evaluation of evidence. [People who hold these assumptions] believe that what they know is absolutely correct, and that they know with complete certainty. People who hold these assumptions treat all problems as though they were well-structured” (King & Kitchener, 2004, p. 39). Example statements typical of Stages 1–3: “I know it because I see it.” “If it’s on Fox News it must be true.”
Quasi-Reflective Reasoning (Stages 4 and 5): Recognition “that knowledge—or more accurately, knowledge claims—contain elements of uncertainty, which [people who hold these assumptions] attribute to missing informa- tion or to methods of obtaining the evidence. Although they use evidence, they do not understand how evidence entails a conclusion (especially in light of the acknowledged uncertainty), and thus tend to view judgments as highly idiosyncratic” (King & Kitchener, 2004, p. 40). Example statements typical of stages 4 and 5: “I would believe in climate change if I could see the proof; how can you be sure the scientists aren’t just making up the data?”
Reflective Reasoning (Stages 6 and 7): People who hold these assumptions accept “that knowledge claims cannot be made with certainty, but [they] are not immobilized by it; rather, [they] make judgments that are ‘most reason- able’ and about which they are ‘relatively certain,’ based on their evaluation of available data. They believe they must actively construct their decisions, and that knowledge claims must be evaluated in relationship to the context in which they were generated to determine their validity. They also readily admit their willingness to reevaluate the adequacy of their judgments as new data or new methodologies become available” (King & Kitchener, 2004, p. 40). Example statements typical of stages 6 and 7: “It is difficult to be certain about things in life, but you can draw your own conclusions about them based on how well an argument is put together based on the data used to support it.”
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204 CHAPTER 7
much on logical grounds as on pragmatic and emo- tional grounds. Rules and norms are viewed as rela- tive, not absolute. Mature thinkers realize thinking is an inherently social enterprise that demands making compromises with other people and tolerating contra- diction and ambiguity. Such shifts mean one’s sense of self also undergoes a fundamental change.
A good example of this developmental shift is the difference between how late adolescents or young adults view an emotionally charged issue—such as unethical behavior at work—compared to the views of middle-aged adults. Younger people may view such behavior as completely inexcusable, with firing of the employee an inescapable outcome. Middle-aged adults may take contextual factors into account and consider what factors may have forced the person to engage in the behavior. Some might argue this is because the topic is too emotionally charged for adolescents to deal with intellectually whereas young adults are better able to incorporate emotion into their thinking.
The integration of emotion with logic in adult- hood provides the basis for decision making in the personal and sometimes difficult arenas of love and work that we examine in detail in Chapters 11 and 12 , respectively. In the present context, integration sets the stage for envisioning one’s future life, a topic we take up later in this chapter.
Implicit Social Beliefs. The developmental integra- tion of thought and emotion during young adulthood and middle age turns out to be influenced by life-cycle forces and cohort effects (see Chapter 1 ). How strongly people hold beliefs vary as a function of how particular generations were socialized.
Social cognition researchers argue individual dif- ferences in the strength of social representations of rules, beliefs, and attitudes are linked to specific situ- ations (Blanchard-Fields, 2009; Labouvie-Vief et al., 2010). Such representations can be both cognitive (how we think about the situation) and emotional (how we react to the situation). When we encounter a specific situation, our cognitive belief system triggers an emotional reaction and related goals tied to the con- tent of that situation demands integration of cognition and emotion. This, in turn, drives social judgments.
Research exploring social beliefs finds age differ- ences in the types of social rules and evaluations evoked in different types of situations (Blanchard-Fields, 2009). When participants considered a husband who chooses to work long hours instead of spending more time with his wife and children, different evaluations about the husband and the marriage emerged. The belief that “marriage is more important than a career” tended to increase in importance with age. As can be seen in Figure 7.5 , this is particularly evident from age
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Figure 7.5 There are age differences in social rules and relationships evoked in different situations. As people grow older, there is an increase in the belief that marriage is more important than achievement in a career; also, older and younger couples may have explanations different from those of middle-aged adults as to why marriages fail. © 2015 Cengage Learning
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 205
24 to age 65 . The social evaluation “the marriage was already in trouble” was also evident and yielded an inverted U-shaped graph; adults between ages 30 and 55 years were most likely to give this evaluation.
One possible explanation for these findings is cohort effects or generational differences (as discussed in Chapter 1 ) influenced whether strong family social rules would be activated (i.e., how cognition and emo- tion interact). Alternatively, the results could also reflect issues concerning different life stages of the respon- dents; the pressures of providing for children may influence how one responds in midlife more so than in early or later adulthood. In any case, social beliefs, as expressed through social rules and evaluations, are powerful influences on how we behave in everyday life. Either way, the developmental shift in the integration of cognition and emotion is an important determinant of age differences in social problem solving.
Neuroimaging Evidence. Evidence from neuroim- aging research indicates emotion and logic processing is indeed integrated in adults (Gu, Liu, Van Dam, Hof, & Fan, 2013). This integration occurs in the prefron- tal cortex and the anterior insula (an area of the brain deep inside the cortex). Additional research reviewed in Chapter 2 indicates the amygdala is also involved in processing emotion, and this information is also inte- grated with thought. This type of integration has been shown to be aberrant in some forms of mental disor- ders (e.g., schizophrenia; Anticevic, Repovs, & Barch, 2012). This means logic and emotion processing share at least some common brain pathways in healthy adults, and these pathways are disrupted in mental disorders..
The integration of emotion with logic that hap- pens in adulthood provides the basis for decision mak- ing in the personal and sometimes difficult arenas of love and work that we examine in detail in Chapters 11 and 12 , respectively. It also provides the basis for broader perspectives about life, and the ability to see points of view different from one’s own.
7.4 Everyday Reasoning and Problem Solving LEARNING OBJECTIVES
What are the characteristics of older adults’ decision making?
What are optimally exercised abilities and unexercised abilities? What age differences have been found in practical problem solving?
What is expertise and how does experience factor in?
What are creativity and wisdom, and how do they relate to age and life experience?
Kim is a 75 -year-old grandmother visiting her 14 -year- old grandson. When he asks her to help with his algebra homework, she declines, stating she just does not have enough schooling to understand it. However, when he has trouble communicating with his parents, Kim can give him excellent advice on how to understand things from both their perspective and his. He ends up getting what he wanted and is delighted to know he can always go to his grandma for advice.
So far, our consideration of intellectual abilities includes examinations of how people’s performance on standardized tests and their modes of thinking differ with age. But what we have not considered in detail is how people actually use their intellectual abilities and demonstrate characteristics we associate with intel- ligent people: solving problems, making decisions, gaining expertise, and becoming wise. This contrast in intellectual abilities is illustrated in Kim’s lack of alge- braic skills, yet wisdom in her interpersonal skills and the conduct of life. What we discovered in this chapter to this point is people’s crystallized intelligence, reflect- ing life experience, continues to grow (or at least not decline) until later in life, and one hallmark of adults’ thinking is the integration of emotion and logic. One might expect, then, the ability to make decisions and solve real-life problems would not decline until late adulthood, that expertise would increase and wisdom would be related to age. Are these expectations cor- rect? Let’s find out.
As we discussed, there are many age-related declines in basic cognitive and sensory mechanisms. We also learned there are age-related increases in experience that continues to build semantic memory and crystallized intelligence, as well as postformal
Adult Development in Action For what types of jobs would an assessment of psy- chometric intelligence be more appropriate than of reflective judgment? What about the other way around?
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206 CHAPTER 7
thinking. Given these two perspectives on aging, an important distinction must be made. Although there are various age-related declines in the structure and processes of cognitive functioning, it is also impor- tant to consider the functional context of everyday behavior that is cognitively demanding. Thus, even though older adults may experience decline in mem- ory, they may have appropriate skills and knowledge adequate for tasks in their daily lives. In other words, we cannot necessarily take information we learn in laboratory experiments on cognitive and intellectual aging and easily apply it to everyday life. Let’s explore this distinction first in the area of everyday decision making.
Decision Making At first glance, the research on decision making suggests older adults make less effective decisions (Besedeš, Deck, Sarangi, & Shor, 2012; Sanfey & Has- tie, 2000). Older adults use less optimal strategies when deciding what options to select to best meet their needs (Besedeš et al., 2012). When decision making involves a high degree of working memory capacity (e.g., a lot of information must be held in memory simultane- ously in order to make quick decisions), older adults do not perform as well (Peters et al., 2007). However, many everyday decision making situations do not
necessarily reflect the firm time constraints and cog- nitive demands studied in typical laboratory research. Let’s examine these situations.
A common everyday decision-making situation involves choosing one best option from a number of choices. These range from assessing automobiles for future purchase (Lambert-Pandraud, Laurent, & Lapersonne, 2005) and treatment decisions for breast cancer (Meyer et al., 2007), to retirement and financial planning (Hershey, Jacobs-Lawson, & Austin, 2013). Findings are quite comparable. Older adults search for less information in order to arrive at a decision, require less information to arrive at a decision, tend to avoid risk, and rely on easily accessible information (Shivapour, Nguyen, Cole, & Denburg, 2012).
When decision-making taps into relevant expe- rience or knowledge, older adults tend to be just as effective or better in making decisions as younger adults. Experience and knowledge tend to make older adults less susceptible to irrational biases in their deci- sion making in comparison to younger adults (Hess, Queen, & Ennis, 2012). It may be when decisions are personally relevant it bolsters older adults’ attentional focus on important cues resulting in efficient decisions (Hess et al., 2012; Meyer et al., 2007). How information search strategies matter is discussed in more detail in the How Do We Know? feature.
HOW DO WE KNOW?: AGE DIFFERENCES IN INFORMATION SEARCH AND DECISION MAKING Who was the investigator and what was the aim of the study? Hess, Queen, and Ennis (2013) were interested in finding out how adults change their information search strategies as the self-relevance of the informa- tion changed. That is, when the information pertains to you personally, it is possible adults use different search strategies than when the information is not personally relevant.
How did the investigator measure the topic of interest? Hess and colleagues used two different deci- sion tasks presented as complex arrays of 48 cells. The two decision tasks involved choosing a wireless phone plan or a prescription drug plan; both are decisions people make in everyday life. Both tasks had eight choice options (the columns in the matrix) and six
attributes (the rows in the matrix). Attribute dimen- sions for the wireless phone plan included: monthly cost, number of minutes, messaging availability, data allowance, overage fees, and geographical coverage. Attributes for the prescription drug plan included: premium, deductible, copay, coverage-gap availabil- ity, pharmacy convenience, and formulary breadth. Cells within matrices contained values describing the choices on each of these dimensions. Clicking on the box for the copay attribute for Plan A in the prescrip- tion drug plan condition revealed a specific monetary value.
Alternatives were presented in eight different orders to control for effects associated with choice posi- tion. A handout describing each attribute dimension for both tasks was provided to eliminate the possibility choice attributes were completely unfamiliar to partici- pants. Only one cell in the matrix could be viewed at a time, mimicking the experience of viewing one web- page at a time in Internet searches.
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 207
Participants in the high-accountability condition were told the following: “As an informed consumer, it is important you make good decisions and can jus- tify the basis for these decisions. Therefore, after you have searched through the information in the array and made your choice, I will also ask you to orally justify the decision you made, including the strategy you used to search through the information and the reasons for choosing the alternative you did.”
Participants in the low-accountability condition were not given any additional instructions.
Intrinsic motivation was measured with the Per- sonal Need for Structure and the Need for Cogni- tion scales. Participants also completed self-reported health and demographics measures, as well as mea- sures of working memory and verbal ability. Finally, they rated the importance of each attribute in the decision tasks and whether they had experience with decisions like the ones they had to make in the experiment.
Who were the participants in the study? 79 younger (aged 21 – 41 years) and 81 older (aged 64 – 90 years) community-dwelling adults participated. Each participant was paid $ 30 .
What was the design of the study? Participants were randomly assigned to a 2 × 2 × 2 (age group × accountability × task) experimental design.
Were there ethical concerns with the study? Participants were volunteers and were provided informed consent, so there were no ethical concerns.
What were the results? The accountability instruc- tions had a disproportionate impact on older adults, who searched the matrices longer than younger adults. All participants viewed more cells in the matrix in the high-accountability than in the low-account- ability conditions. The relevance of the information had a bigger impact on older adults’ searches than on younger adults’ searches. In low relevance tasks, both younger and older adults tended to use an attri- bute-based approach; participants chose an attribute and compared different alternatives along the same attribute dimension (e.g., compared different phones along the same dimension of number of minutes in the plan). The high relevance task increased the use of alternative-based strategies; respondents compare the same alternative across different attributes (e.g., look at the same phone across multiple attributes such as minutes, messaging, and cost).
What did the investigators conclude? Hess and colleagues concluded older adults are adaptive deci- sion makers, adjusting their strategies based on task demands. Both the relevance of the information and the accountability of the decision affect search strategies.
An area that received considerable attention is the role emotion plays in age differences in deci- sion making. Negative emotions such as anger and fear can be evoked when making a decision. Health- related decisions are particularly distasteful because they can involve threat, are high in personal relevance and high importance to the individual (Lockenhoff & Carstensen, 2007). In support of the idea older adults are motivated to reduce the experience of negativity and enhance the experience of positivity (Carstensen & Mikels, 2005), research shows older adults focused more on positive information when making a health decision (Lockenhoff & Carstensen, 2007). Interest- ingly Kim and colleagues (2008) found older adults focused more on positive information than younger adults did when making a decision only when they were asked to explicitly evaluate their options before making a choice. If not asked to do so, there were no age differences in decision making.
Furthermore, these researchers asked participants how satisfied they were with their decision. For the
older adult group asked to evaluate their options, their focus on the positive and satisfaction with their deci- sion remained high over two weeks. In other words, older adults’ high level of satisfaction with their deci- sions increased and persisted over two weeks by sim- ply asking them to spend a few minutes evaluating their options. This did not happen for younger adults. Kim et al. (2008) comment on how advertisements or interventions having a positive impact on one age group may have a completely different impact on another.
Problem Solving One of the most important ways people use their intel- lectual abilities is to solve problems. Think for a minute about everyday life and the number of problem-solving situations you encounter in school, on the job, in rela- tionships, driving a car, and so forth. Each of these settings requires you to analyze complex situations quickly, to apply knowledge, and to create solutions, sometimes in a matter of seconds.
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208 CHAPTER 7
Some people tend to be better at dealing with cer- tain problems more than with others. Why is that? One possible explanation has to do with the kinds of abili- ties we use regularly versus the abilities we use only occasionally. Nancy Denney proposed a more formal version of this explanation that we consider next.
Denney’s Model of Unexercised and Optimally Exercised Abilities. Denney (1984) postulates intel- lectual abilities relating to problem solving follow two types of developmental functions. One of these functions represents unexercised or unpracticed ability, and the other represents optimally trained or optimally exercised ability. Unexercised ability is the ability a normal, healthy adult would exhibit with- out practice or training. Fluid intelligence is thought to be an example of untrained ability, because by definition, it does not depend on experience and is unlikely to be formally trained (Horn & Hofer, 1992). Optimally exercised ability is the ability a normal, healthy adult would demonstrate under the best condi- tions of training or practice. Crystallized intelligence is an example of optimally exercised ability, because the component skills (such as vocabulary ability) are used daily.
Denney argues the overall developmental course of both abilities is the same: They tend to increase until late adolescence or early adulthood and slowly decline thereafter. At all age levels there is a difference in favor of optimally exercised ability, although this difference is less in early childhood and old age. As the develop- mental trends move away from the hypothetical ideal, Denney argues the gains seen in training programs will increase. As we noted earlier in our discussion of attempts to train fluid intelligence, it appears this increase occurs.
Practical Problem Solving. Denney’s model spurred considerable interest in how people solve practical problems. Based on the model, adults should perform better on practical problems than on abstract ones like those typically used on standardized intelligence tests. Tests of practical problem solving would use situations such as the following (Denney et al., 1982): “Let’s say that a middle-aged woman is frying chicken in her home when, all of a sudden, a grease fire breaks out on top of the stove. Flames begin to shoot up. What should she do?” ( 116 ) .
One way to assess practical problem solving in more focused terms is to create measures with clearly identifiable dimensions that relate to specific types of problems (Allaire, 2012). This is what Diehl, Willis, and Schaie (1995) did by creating the Observed Tasks of Daily Living (OTDL) measure. The OTDL consists of three dimensions that reflect three specific problems in everyday life: food preparation, medication intake, and telephone use. Each of these dimensions also reflects important aspects of assessing whether people can live independently, a topic we explored in Chapter 5 . Diehl et al. showed performance on the OTDL is directly influenced by age, fluid intelligence, and crystallized intelligence and indirectly by perceptual speed, mem- ory, and several aspects of health. These results provide important links between practical problem solving and basic elements of psychometric intelligence and infor- mation processing. However, more recent study find- ings indicate basic measures of inductive reasoning, domain-specific knowledge, memory, and working memory were related to everyday assessments of each of these abilities (Allaire, 2012; Thornton & Dumke, 2005). Allaire and Marsiske (1999, 2002) conclude everyday problems reflecting well-structured chal- lenges from activities of daily living show a strong rela- tionship to traditional psychometric abilities.
The search for relations between psychometric intelligence and practical problem-solving abilities is only one way to examine the broader linkages with intellectual functioning. It focuses on the degree of how everyday problem solving is a manifestation of underlying intellectual abilities (Berg, 2008). How- ever, recall post-formal thinking is grounded in the ways people conceptualize situations. Indeed, much of the research that led to the discovery of post-formal thought involved presenting adults with lifelike prob- lems. This approach enlarges the scope of what we consider everyday problem solving to include not just cognitive abilities, but also social, motivational, and cultural factors influencing how we solve problems (Berg, 2008).
Another important factor that influences the way we solve everyday problems is the context in which the problem occurs. Do we use the same strategies when solving a family conflict between two siblings as we do when solving a conflict over the leading role in a proj- ect at work? The answer is no. Interestingly, however,
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 209
age differences reveal younger adults are more likely to use a similar strategy across problem-solving con- texts: self-action in order to fix the problem. Older adults, on the other hand, are more likely to vary their strategy given the problem-solving context. In inter- personal conflict problems (e.g., family conflict) they use more emotion-regulating strategies (i.e., manag- ing their emotions) whereas in instrumental situations (e.g., dealing with defective merchandise) they use self-action strategies (return the product) (Blanchard- Fields et al., 1997). Blanchard-Fields et al. (1997) argue as we grow older and accumulate more everyday expe- rience, we become more sensitive to the problem con- text and use strategies accordingly.
There are also individual differences in the way the same problem situation is interpreted. How individuals represent problems differs and could vary across the life span as developmental life goals change (Berg et al., 1998). Berg and colleagues (Berg et al., 1998; Strough et al., 1996) find there are age differences in how indi- viduals define their own everyday problems. Overall, middle-aged older adults defined problems more in terms of interpersonal goals (e.g., getting along with a person or spending more time with an individual), whereas adolescents and young adults focused more on competence goals (e.g., losing weight or studying for an exam). Furthermore, problem-solving strate- gies fit the problem definitions. Older adults defined problems more in terms of interpersonal concerns and subsequently reported strategies such as regulating others or including others, whereas competence goals resulted in strategies that involved more self-action. Along these lines Artistico, Cervone, and Pezzuti (2003) found older adults were more confident and generated more effective solutions to problems typi- cal of the life stage of older adults. Finally, Blanchard- Fields, Mienaltowski, and Seay (2007) found older adults were rated as more effective in their everyday problem-solving strategy use than younger adults across all types of problem situations.
What can we conclude from the research on prac- tical problem solving? First, practical problem-solving abilities are multidimensional and may not interrelate strongly with each other. Second, the developmen- tal functions of these abilities are complex and may differ across abilities. Third, the relations between practical problem-solving abilities and psychometric
intelligence are equally complex. Finally, the close con- nection between solving practical problems and emo- tion and motivation may prove fruitful in furthering our understanding of individual differences in abilities. In short, solving practical problems offers an excellent way to discover how all the topics we have considered in this chapter come together to produce behavior in everyday life.
Expertise We saw earlier in this chapter aspects of intelligence grounded in experience (crystallized intelligence) tend to improve throughout most of adulthood. In a real- world experiential perspective, each of us becomes an expert at something important to us, such as our work, interpersonal relationships, cooking, sports, or auto repair. In this sense, an expert is someone who is much better at a task than people who have not put much effort into it. We tend to become selective experts in some areas while remaining amateurs or novices at others.
What makes experts better than novices? It’s how experts handle the problem (Ericsson & Towne, 2010). For novices, the goal for accomplishing the activity is to reach as rapidly as possible a satisfactory perfor- mance level that is stable and “autonomous.” In con- trast, experts build up a wealth of knowledge about alternative ways of solving problems or making deci- sions. These well-developed knowledge structures are the major difference between experts and novices, and they enable experts to bypass steps needed by nov- ices (Chi, 2006). Experts don’t always follow the rules as novices do; they are more flexible, creative, and
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210 CHAPTER 7
curious; and they have superior strategies grounded on superior knowledge for accomplishing a task (Ericsson & Towne, 2010). Even though experts may be slower in terms of raw speed because they spend more time planning, their ability to skip steps puts them at a decided advantage. In a way, this represents “the triumph of knowledge over reasoning” (Charness & Bosman, 1990).
What happens to expertise over the adult life span? Research evidence indicates expert performance tends to peak by middle age and drops off slightly after that (Masunaga & Horn, 2001). However, the declines in expert performance are not nearly as great as they are for the abilities of information processing, memory, and fluid intelligence that underlie expertise, and expertise may sometimes compensate for declines in underlying cognitive abilities (Masunaga & Horn, 2001; Taylor et al., 2005).
Such compensation is seen in expert judgments about such things as how long certain figure skating maneuvers will take. Older people who were experts were as good as younger adults who were still skating at predicting the amount of time skating moves take (Diersch, Cross, Stadler, Schütz-Bosbach, & Rieger, 2012). Thus, it appears knowledge based on experi- ence is an important component of expertise. But how do people keep acquiring knowledge? That’s achieved through lifelong learning.
Lifelong Learning. Many people work in occupa- tions where information and technology change rapidly. To keep up with these changes, many orga- nizations and professions now emphasize the impor- tance of learning how to learn, rather than learning specific content that may become outdated in a cou- ple of years. For most people, a college education will probably not be the last educational experience they have in their careers. Workers in many professions— such as medicine, nursing, social work, psychology, auto mechanics, and teaching—are now required to obtain continuing education credits to stay current in their fields. Online learning has made lifelong learn- ing more accessible to professionals and interested adults alike (Fretz, 2001; Ranwez, Leidig, & Crampes, 2000), but open access to computers for these pro- grams needs to be in supportive, quiet environments (Eaton & Salari, 2005).
Lifelong learning is gaining acceptance as the best way to approach the need for keeping active cog- nitively, and is viewed as critical part of aging glob- ally (Swindell, 2012), but should lifelong learning be approached as merely an extension of earlier educa- tional experiences? Knowles, Swanson, and Holton (2005) argue teaching aimed at children and youth differs from teaching aimed at adults. Adult learners differ from their younger counterparts in several ways:
Adults have a higher need to know why they should learn something before undertaking it.
Adults enter a learning situation with more and different experience on which to build.
Adults are most willing to learn those things they believe are necessary to deal with real-world prob- lems rather than abstract, hypothetical situations.
Most adults are more motivated to learn by internal factors (such as self-esteem or personal satisfaction) than by external factors (such as a job promotion or pay raise).
Lifelong learning is becoming increasingly impor- tant, but educators need to keep in mind learning styles change as people age. Effective lifelong learning requires smart decisions about how to keep knowl- edge updated and what approach works best among the many different learning options available (Janssen et al., 2007).
Creativity and Wisdom Two additional aspects of cognition examined for age- related differences are creativity and wisdom. Each has been the focus of stereotypes: creativity is assumed to be a function of young people, whereas wisdom is assumed to be the province of older adults. Let’s see whether these views are accurate.
Creativity. What makes a person creative? Is it excep- tional productivity? Does creativity mean having a career marked by precocity and longevity?
Researchers define creativity in adults as the abil- ity to produce work that is novel, high in demand, and task appropriate (Sternberg & Lubart, 2001). Creative output, in terms of the number of creative ideas a per- son has or the major contributions a person makes, varies across the adult life span and disciplines (Jones,
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 211
2010; Kozbelt & Durmysheva, 2007; Simonton, 2012). When considered as a function of age, the overall number of creative contributions a person makes tends to increase through one’s 30 s, peak in the early 40 s, and decline thereafter. The age-related decline does not mean people stop being creative altogether, just that they produce fewer creative ideas than when they were younger (Dixon & Hultsch, 1999). In fact, the age when people made major creative contribu- tions, such as research that resulted in winning the Nobel Prize, increased throughout the 20 th century (Jones, 2010).
Exciting neuroimaging research is supporting previous research that one’s most innovative contri- bution tends to happen most often during the 30 s or 40 s, as well as showing that creative people’s brains are different. This new research shows white matter brain structures that connect distant brain regions, and coordinate the cognitive control of information among them, are related to creativity and are more apparent in creative people (Jung et al., 2010; Takeuchi et al., 2010). Additional neuroimaging research shows different areas of the prefrontal and parietal areas are responsible for different aspects of creative thinking (Abraham, Beudt, Ott, & von Cramon, 2012). This research supports the belief creativity involves con- necting disparate ideas in new ways, as different areas of the brain are responsible for processing different kinds of information. Because white matter tends to change with age, this finding also suggests there are underlying brain maturation reasons why innovative thinking tends to occur most often during late young adulthood and early middle age.
Wisdom. For thousands of years, cultures around the world greatly admired people who were wise. Based on years of research using in-depth think-aloud inter- views with young, middle-aged, and older adults about normal and unusual problems people face, Baltes and colleagues (Ardelt, 2010; Baltes & Staudinger, 2000; Scheibe, Kunzmann, & Baltes, 2007) describe four characteristics of wisdom:
Wisdom deals with important or difficult matters of life and the human condition.
Wisdom is truly “superior” knowledge, judgment, and advice.
Wisdom is knowledge with extraordinary scope, depth, and balance that is applicable to specific situations.
Wisdom, when used, is well intended and com- bines mind and virtue (character).
Researchers used this framework to discover that people who are wise are experts in the basic issues in life (Ardelt, 2010; Baltes & Staudinger, 2000). Wise people know a great deal about how to conduct life, how to interpret life events, and what life means. Kunz (2007) refers to this as the strengths, knowledge, and understanding learned only by living through the ear- lier stages of life.
Research studies indicate contrary to what many people expect, there is no association between age and wisdom (Ardelt, 2010; Baltes & Staudinger, 2000; De Andrade, 2000; Hartman, 2001). As envisioned by Baltes and colleagues, whether a person is wise depends on whether he or she has extensive life expe- rience with the type of problem given and has the req- uisite cognitive abilities and personality. Thus, wisdom could be related to crystallized intelligence, knowledge that builds over time and through experience (Ardelt, 2010).
Culture matters, though, in understanding wis- dom. Younger and middle-aged Japanese adults use more wisdom-related reasoning strategies (e.g., recog- nition of multiple perspectives, the limits of personal knowledge, and the importance of compromise) in resolving social conflicts than younger or middle-aged Americans (Grossman, Karasawa, Izumi, Na, Varnum, Kitayama et al., 2012). However, older adults in both cultures used similar wisdom-related strategies.
So what specific factors help one become wise? Baltes (1993) identified three factors: (1) general per- sonal conditions such as mental ability; (2) specific expertise conditions such as mentoring or practice; and (3) facilitative life contexts such as education or leadership experience. Personal growth during adult- hood, reflecting Erikson’s concepts of generativity and integrity also fosters the process, as do facing and dealing with life crises (Ardelt, 2010). All of these factors take time. Thus, although growing old is no guarantee of wisdom, it does provide the time, if used well, creates a supportive context for developing wisdom.
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212 CHAPTER 7
Becoming wise is one thing; having one’s wisdom recognized is another. Interestingly, peer ratings of wis- dom are better indicators of wisdom than self-ratings (Redzanowski & Glück, 2013). It appears people are better at recognizing wisdom in others than they are in themselves. Perhaps it is better that way.
Interestingly, there is a debate over whether with wisdom comes happiness. There is research evidence that wise people are happier (Bergsma & Ardelt, 2012; Etezadi & Pushkar, 2013). Wise people tend to have higher levels of perceived control over their lives and use problem-focused and positive reappraisal coping
strategies more often than people who are not wise. On the other hand, some evidence indicates the attain- ment of wisdom brings increased distress (Staudinger & Glück, 2011). Perhaps because with the experience that brings wisdom comes an understanding that life does not always work out the way one would like.
Adult Development in Action If you were the director of a senior center, how would you capitalize on the wisdom of your members?
Social Policy Implications In the section on training, evidence suggests a cogni- tively enriched lifestyle can positively influence intel- lectual change as we grow older. This suggests there is promise in developing long-term cognitive enrich- ment programs to reduce morbidity and dependence in older adults. For example, it may be the case we can defer the need for assisted living, improve well-being, and reduce health care costs. Projects aimed at train- ing intellectual abilities in older adult populations thus have important public policy implications in terms of funding priorities and reducing the burden on public funding for disabilities in senior citizens. The long-term goals of projects such as ACTIVE is to reduce public health problems associated with the increasing need for more formal care and hospital- ization along with the loss of independence in the growing number of American senior citizens.
Richard M. Suzman, Ph.D., Director for the Behav- ioral and Social Research Program at the National Institute on Aging (NIA), says,
The trial ( ACTIVE trials ) was highly successful in showing that we can, at least in the laboratory, improve certain thinking and reasoning abilities in older people. The findings here were powerful and very specific. Although they did not appear to make any real change in the actual, daily activities of the participants, I think we can build on these results to see how training ultimately might be applied to tasks that older people do every day, such as using medica- tion or handling finances. This intervention research, aimed at helping healthy older people maintain cognitive status as they age, is an increasingly high priority of the NIH/National Institute on Aging.
Summary 7.1 Defining Intelligence
How Do People Define Intelligence In Everyday Life? Experts and laypeople agree intelligence consists of
problem-solving ability, verbal ability, and social com- petence. Motivation, exertion of effort, and reading are important behaviors for people of all ages; how- ever, some age-related behaviors are also apparent.
What are the major components of the life-span approach?
The life-span view emphasizes there is some intel- lectual decline with age, primarily in the mechan- ics, but there is also stability and growth, primarily
in the pragmatics. Four points are central. Plasticity concerns the range within one’s abilities are modi- fiable. Multidimensionality concerns the many abil- ities that underlie intelligence. Multidirectionality concerns the many possible ways individuals may develop. Interindividual variability acknowledges people differ from each other.
What are the major research approaches for studying intelligence?
Three main approaches are used to study intel- ligence. The psychometric approach focuses on performance on standardized tests. The cognitive- structural approach emphasizes the quality and style of thought. The information-processing approach emphasis basic cognitive mechanisms.
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 213
7.2 Developmental Trends in Psychometric Intelligence
What is intelligence in adulthood? Intellectual abilities fall into various related abili-
ties that form the structure of intelligence. Intelligence in adulthood focuses on how it oper-
ates in everyday life.
What are primary mental abilities and how do they change across adulthood?
Primary abilities comprise the several independent abilities that form factors on standardized intelli- gence tests. Five have been studied most: number, word fluency, verbal meaning, inductive reasoning, and spatial orientation.
Primary mental abilities show normative declines with age that may affect performance in everyday life after around age 60 , although declines tend to be small until the mid- 70 s. However, within indi- vidual differences show few people decline equally in all areas.
What are fluid and crystallized intelligence? How do they change?
Fluid intelligence involves innate abilities that make people flexible and adaptive thinkers and underlie the acquisition of knowledge and experience. Fluid intelligence normally declines with age. Crystal- lized intelligence is knowledge acquired through life experience and education. Crystallized intelli- gence does not normally decline with age until late life. As age increases, individual differences remain stable with fluid intelligence but increase with crys- tallized intelligence.
Age-related declines in fluid abilities have been shown to be moderated by cohort, education, social variables, personality, health, lifestyle, and task familiarity. Cohort effects and familiarity have been studied most. Cohort differences are complex and depend on the specific ability. Age differences in performance on familiar tasks are similar to those on standardized tests. Although taking both into account reduces age differences, they are not eliminated.
Several studies show that fluid intelligence abili- ties improve after direct training and after anxiety reduction. Improvements in performance match or exceed individuals’ level of decline. Training effects appear to last for several years regardless of the nature of the training, but generalization of train- ing to new tasks is rare.
7.3 Qualitative Differences in Adults’ Thinking
What are the main points in Piaget’s theory of cognitive development?
Key concepts in Piaget’s theory include adaptation to the environment, organization of thought, and the structure of thought. The processes of thought are assimilation (using previously learned knowl- edge to make sense of incoming information) and accommodation (making the knowledge base con- form to the environment). According to Piaget, thought develops through four stages: sensorimo- tor, preoperations, concrete operations, and formal operations.
What evidence is there for continued cognitive development beyond formal operations?
Considerable evidence shows the style of think- ing changes across adulthood. The development of reflective judgment in young adulthood occurs as a result of seven stages. Other research identi- fied a progression from absolutist thinking to relativistic thinking to dialectical thinking. A key characteristic of post-formal thought is the integra- tion of emotion and logic. Much of this research is based on people’s solutions to real-world problems. Although there have been suggestions that wom- en’s ways of knowing differ from men’s, research evidence does not provide strong support for this view.
7.4 Everyday Reasoning and Problem Solving
What are the characteristics of older adults’ decision making?
Older adults make decisions in a qualitatively differ- ent way from younger adults. They tend to search for less information, require less information, and rely on preexisting knowledge structures in mak- ing everyday decisions. Older adults perform more poorly when asked to create or invent new decision rules, in unfamiliar situations, and when the deci- sion task requires high cognitive load.
What age differences are found in practical problem solving?
In Denney’s model, both unexercised and optimally exercised abilities increase through early adult- hood and slowly decline thereafter. Performance on practical problem solving increases through middle age. Research indicates sound measures of practical problem solving can be constructed, but these measures do not tend to relate to each other,
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214 CHAPTER 7
indicating problem solving is multidimensional. The emotional salience of problems is an important feature that influences problem-solving style with older adults performing better when problems involve interpersonal and emotional features.
What is the role of experience in expertise and problem solving?
Older adults can often compensate for declines in some abilities by becoming experts that allows them to anticipate what is going to be required on a task. Knowledge encapsulation occurs with age, when the processes of thinking become connected with the products of thinking. Encapsulated knowl- edge cannot be decomposed and studied compo- nent by component.
What is wisdom and how does it relate to age and life experience?
Wisdom involves four general characteristics: it deals with important matters of life; consists of superior knowledge, judgment, and advice; is knowledge of exceptional depth; and is well inten- tioned. Five specific behavioral criteria are used to judge wisdom: expertise, broad abilities, under- standing how life problems change, fitting the response with the problem, and realizing life prob- lems are often ambiguous. Wisdom also entails integrating thought and emotion to show empa- thy or compassion. Wisdom may be more strongly related to experience than age.
Review Questions 7.1 Defining Intelligence
How do laypeople and researchers define intelli- gence?
What are the two main ways intelligence has been studied? Define each.
7.2 Developmental Trends in Psychometric Intelligence
What are primary mental abilities? Which ones have been studied most? How do they change with age?
Define fluid and crystallized intelligence. How does each change with age?
What factors moderate age changes in fluid intel- ligence? What role does cohort play? What role do health and lifestyle play?
What benefits do older people get from interven- tion programs aimed at improving fluid abilities? What training approaches have been used? How well do trained skills generalize?
Are there any limitations on the extent that older adults can improve their cognitive perfor- mance?
7.3 Qualitative Differences in Adults’ Thinking What are the key concepts in Piaget’s theory? What stages of cognitive development did Piaget
identify? Do adults use formal operations? What is reflective judgment? What are the stages
in its development? What are absolutist, relativis- tic, and dialectical thinking?
How do emotion and logic become integrated? What evidence is there for gender differences in
post-formal thinking?
7.4 Everyday Reasoning and Problem Solving How do older adults differ from younger adults in
everyday decision making? What are unexercised and optimally exercised abili-
ties? How do their developmental paths differ from each other?
What are the developmental trends in solving prac- tical problems? How does emotional salience of problems influence problem-solving style?
What is an expert? How is expertise related to age? What is knowledge encapsulation? What criteria are used to define wisdom? How is
wisdom related to age?
INTEGRATING CONCEPTS IN DEVELOPMENT How are the primary and secondary mental abili-
ties related to the aspects of information process- ing considered in Chapters 6 and 7 ?
What do you think an integrated theory linking post-formal thinking, practical problem solving, expertise, and wisdom would look like?
What aspects of secondary mental abilities do you think would be most closely linked to expertise? Why?
How does effective social cognitive functioning considered in Chapter 9 relate to wisdom-related behaviors?
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INTELLIGENCE, REASONING, CREATIVITY, AND WISDOM 215
KEY TERMS accommodation Changing one’s thought to better approximate the world of experience.
assimilation Using currently available knowledge to make sense out of incoming information.
cognitive-structural approach An approach to intelligence that emphasizes the ways people conceptualize problems and focuses on modes or styles of thinking.
crystallized intelligence Knowledge acquired through life experience and education in a particular culture.
factor The interrelations among performances on similar tests of psychometric intelligence.
fluid intelligence Abilities that make one a flexible and adaptive thinker, that allow one to draw infer- ences, and allow one to understand the relations among concepts independent of acquired knowledge and experience.
interindividual variability An acknowledgment adults differ in the direction of their intellectual development.
mechanics of intelligence The aspect of intelligence that concerns the neurophysiological architecture of the mind.
multidimensional The notion intelligence consists of many dimensions.
multidirectionality The distinct patterns of change in abilities over the life span, with these patterns being different for different abilities.
neural efficiency hypothesis States intelligent people process information more efficiently, showing weaker neural activations in a smaller number of areas than less intelligent people.
optimally exercised ability The ability a normal, healthy adult would demonstrate under the best con- ditions of training or practice.
plasticity The range of functioning within an indi- vidual and the conditions under which a person’s abilities can be modified within a specific age range.
post-formal thought Thinking characterized by a recognition that truth varies across situations, solutions must be realistic to be reasonable, ambiguity and con- tradiction are the rule rather than the exception, and emotion and subjective factors play a role in thinking.
pragmatic intelligence The component of intelligence that concerns acquired bodies of knowledge available from and embedded within culture.
primary mental abilities Independent abilities within psychometric intelligence based on different combina- tions of standardized intelligence tests.
psychometric approach An approach to intelligence involving defining it as performance on standardized tests.
reflective judgment Thinking that involves how peo- ple reason through dilemmas involving current affairs, religion, science, and the like.
secondary mental abilities Broad-ranging skills com- posed of several primary mental abilities.
structure of intelligence The organization of interre- lated intellectual abilities.
unexercised ability The ability a normal, healthy adult would exhibit without practice or training.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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Social Cognition
8.1 STEREOTYPES AND AGING Content of Stereotypes • Age Stereotypes and Perceived Competence • Activation of Stereotypes • Stereotype Threat • Current Controversies: Are Stereotypes of Aging Associated with Lower Cognitive Performance?
8.2 SOCIAL KNOWLEDGE STRUCTURES AND BELIEFS Understanding Age Differences in Social Beliefs • Self-Perception and Social Beliefs • How Do We Know?: Age Differences in Self-Perception
8.3 SOCIAL JUDGMENT PROCESSES Impression Formation • Knowledge Accessibility and Social Judgments • A Processing Capacity Explanation for Age Differences in Social Judgments • Attributional Biases
8.4 MOTIVATION AND SOCIAL PROCESSING GOALS Personal Goals • Emotion as a Processing Goal • Cognitive Style as a Processing Goal
8.5 PERSONAL CONTROL Multidimensionality of Personal Control • Discovering Development: How Much Control Do You Have over Your Cognitive Functioning? • Control Strategies • Some Criticisms Regarding Primary Control
8.6 SOCIAL SITUATIONS AND SOCIAL COMPETENCE Collaborative Cognition • Social Context of Memory SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 8
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SOCIAL COGNITION 217
When a prominent Democrat married a prominent Republican in 1992, both of whom were the top consultants to the compet- ing presidential candidates that year, people had difficulty making sense of it. Many thought the marriage of Mary Matalin (George H. W. Bush’s political director) and James Carville (Bill Clinton’s campaign strategist) was doomed because they were political “opposites.” In contrast, the newly- weds saw their passion for politics as a core similar- ity, and, more than 20 years later, are still married and consulting for different political parties (you may have seen them on various news networks).
The public wonderment about the Matalin– Carville relationship and marriage illustrates how people try to make sense of other people’s behav- ior. Just as James and Mary are viewed through the stereotypes of political affiliation, all of us use social cognition as a way to make sense of the people and the world around us. As we will see, this is the essence of social cognitive functioning.
In this chapter, we consider how the social context is involved in our cognitive processes. We take a closer look at how our basic cognitive abilities influence our social cognitive processing. We examine how our past experiences and beliefs influence our social judgment processes such as how people make impressions and explain behav- ior (causal attributions). Finally we examine four aspects of social cognition: the role of motivation and emotion as processing goals, the way stereo- types affect how we judge older adults’ behavior, the amount of personal control people feel they have, and how cognition is affected when we com- municate with others in a social context.
First we need to highlight the importance of social-contextual aspects of cognition in terms of stereotypes. We are confronted with images of older adults all the time through cartoons, advertisements for medical products, jokes on greeting cards, and art. Many of these images are negative (e.g., older adults are terribly for- getful, slow, and easily confused) but some are positive (e.g., older adults are wise). The impact of these stereotypes on our lives is more perva- sive than you may think. We’ll explore some of these influences.
Additionally, social cognition research raised some important issues for aging research such as how our life experiences and emotions, as well as changes in our pragmatic knowledge, social expertise, and values, influence how we think and remember. To address these issues, we must con- sider both the basic cognitive architecture of the aging adult (identified in Chapter 6 ) and the func- tional architecture of everyday cognition (discussed in Chapter 7 ). Even if basic cognitive mechanisms decline (such as episodic memory recall or speed of processing) older adults still have the social knowl- edge and skills that allow them to function effec- tively. In fact, by taking into consideration social and emotional factors, researchers find older adults’ cognitive functioning often remains intact and may even improve across the life span (Blanchard- Fields, Horhota, & Mienaltowski, 2008; Carstensen & Mikels, 2005; Hess, 2005). This approach reinforces the perspective of this textbook that views effective development as a lifelong adaptive process.
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8.1 Stereotypes and Aging LEARNING OBJECTIVES
How does the content of stereotypes about aging differ across adulthood?
How do younger and older adults perceive the competence of the elderly?
How do negative stereotypes about aging unconsciously guide our behavior?
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218 CHAPTER 8
Mark, a 70 -year-old man, was getting ready to go home from a poker game at his friend’s house. However, he could not find his keys. Down the street, Guy, a 20 -year- old college student, was ready to pick up his girlfriend and he could not find his keys. Each of their respective friends at the two social events had different perceptions of Mark and Guy. Mark’s friends started to worry whether Mark was becoming senile, speculating it might be all downhill from now on. They wondered whether this was serious enough to call the doctor. However, Guy’s friends attrib- uted his forgetfulness to being busy, under a lot of stress, and nervous about his upcoming date.
What accounts for these different explanations of losing one’s keys for Mark and Guy? An explanation for the attributions Mark’s friends made involves the negative stereotype of aging that older adults are slow- thinking and incompetent. Negative stereotypes of aging are extremely pervasive throughout our culture. Just peruse your local greeting card store and you will find humorous birthday cards capitalizing on our neg- ative expectations about aging. Jokes run amuck about the older adult who keeps losing his or her memory. This captures all our negative stereotypes about mem- ory and aging.
In contrast, the same behavior in a young adult holds very different meaning for most people; stress, preoccupation, lack of attention, and other explana- tions are used. Rarely is the cause attributed to a young adult’s declining cognitive ability.
Fortunately, positive expectations about aging coexist with the negative ones, and stereotypes can be changed (Wurtele & Maruyama, 2013). Older adults are subjected to conflicting stereotypes. On the one hand, older adults are seen as grouchy, forgetful, and losing physical stamina and sexual abilities. On the other hand, older adults are seen as wise, generous, and responsible. The important question researchers ask is what effect stereotypes have on our social judg- ments and our behavior toward others, such as those in Mark’s situation.
Content of Stereotypes Stereotypes are a special type of social knowledge struc- ture or social belief. They represent socially shared beliefs about characteristics and behaviors of a particular social group. We all have stereotypes of groups of people and beliefs about how they will act in certain situations,
such as “Older adults are more rigid in their point of view” or “Older adults talk on and on about their past.”
These beliefs affect how we interpret new infor- mation. In other words, we use stereotypes to help us process information when engaged in social interac- tions. Just as with the literature on impression forma- tion discussed earlier, we use stereotypes to size up people when we first meet them. This categorizing helps us understand why they behave the way they do and guides us in our behavior toward other people. Remember, stereotypes are not inherently negative in their effect. However, too often they are applied in ways that underestimate the potential of the person we are observing. This becomes more evident as we explore age-related stereotypes.
Much research has examined adult developmen- tal changes in the content and structure of stereotypes (e.g., Hayslip, Caballero, Ward-Pinson, & Riddle, 2013). From a developmental perspective we ask if there are changes in the nature and strength of our stereotypes as we grow older. Overall, the consensus is growing that adults of all ages have access to mul- tiple stereotypes of older adults (Cuddy & Fiske, 2002; Truxillo, McCune, Bertolino, & Fraccaroli, 2012).
There are also age differences in how we perceive older adults. The consensus on stereotype categories across age groups just depicted above is accompanied by developmental changes in the complexity of age stereotype beliefs. The ability to estimate the age of someone by seeing their face decreases with age, but older adults are better with their age group than are younger adults at judging older faces (Voelkle, Ebner, Lindenberger, & Riediger, 2012). Other studies show older adults identify more categories that fit under the superordinate category “older adult” than do younger and middle-aged adults (Hayslip et al., 2013). Overall, these findings suggest as we grow older, our ideas and age stereotypes become more elaborate and rich as we integrate our life experiences into our beliefs about aging (Baltes et al., 2006; O’Brien & Hummert, 2006).
Are there age differences in how negatively or positively people view older adults? Research indicates older adults have a more positive view of aging in com- parison to younger adults (Wentura & Brandtstädter, 2003), a finding that holds cross-culturally, such as in Brazil (de Paula Couto & Koller, 2012). As the baby boom generation ages and redefines what being old
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SOCIAL COGNITION 219
means, it will be interesting to see whether stereotypes about older adults also change.
Age Stereotypes and Perceived Competence
Stereotypes are not simply reflected in our perceptions of what we think are representative personality traits or characteristics of older adults. We also make apprais- als or attributions of older adults’ competence when we observe them perform tasks and we assess whether we can count on them to perform important tasks. No area is more susceptible to negative stereotyped attributions of aging than memory competence. As we discussed in Chapter 6 , people of all ages believe memory decreases with age and we have less and less control over current and future memory functioning as we grow older.
The interesting question is, how does this strong belief in age-related loss of memory affect our attri- butions (explanations) about older adults’ competen- cies? In an elegant and classic series of studies, Joan Erber (e.g., Erber & Prager, 1999) found an age-based double standard in judging the competence of old ver- sus young adults. The age-based double standard is operating when an individual attributes an older per- son’s failure in memory as more serious than a memory failure observed in a young adult. So if an older woman cannot find her keys, this is seen as a much more seri- ous memory problem (e.g., possibly attributed to senil- ity) than if a younger woman cannot find her keys. The age-based double standard is most evident when younger people are judging the memory failure.
In contrast, when older people observe the same memory failure, they tend to judge both young and old targets of the story more equally. In fact, most of the time older adults are more lenient toward mem- ory failures in older adults. However, in other types of competence judgments, older adults also display the age-based double standard. When assessing the cause of a memory failure, both younger and older people felt the failure was due to greater mental difficulty in the case of an older adult, whereas for younger adults participants attributed it to a lack of effort or attention (Erber et al., 1990).
The preceding tasks involve global explanations of memory failures in younger and older adults. How- ever, what happens when you are asked to decide if an older adult should get a job or perform a task that
demands memory capabilities? In several studies Erber and colleagues presented younger and older partici- pants with an audiotaped interview of people applying for various volunteer positions, such as in a museum (Erber & Long, 2006; Erber & Szuchman, 2002). The applicant was either old or young, and either forget- ful or not forgetful. They found despite the age-based double standard in judging older adults’ memory fail- ures found in earlier studies, people (both young and old) had more confidence in and would assign tasks or jobs to nonforgetful people irrespective of age.
What accounts for this apparent discrepancy in findings? Maybe, when forming an impression about someone’s capability, people take other factors into consideration. For example, traits could come into play, such as how responsible the person is. Remem- ber stereotypes about older adults included many positive ones, including being responsible. In fact, young adults were asked whom they would choose to be a neighbor they could rely on. Despite forgetful- ness ratings, they consistently chose older neighbors over younger ones. They also judged older neighbors to be more responsible, reliable, dependable, and helpful than younger ones. Thus, being able to access these positive traits may have compensated for older neighbors’ forgetfulness. In a recent follow-up study, younger and older adults rated both younger and older targets similarly on negative traits such as for- getfulness; however, only the older targets were rated higher on desirable traits such as responsibility (Erber & Szuchman, 2002).
What can we conclude from the trait studies of stereotypes and the attribution studies of stereotypes? First, when more individualized information (e.g., providing an audiotaped interview of the person) is provided and the individual is considered in a social setting (e.g., a volunteer position interview, a neigh- borly interaction), people consider more than just negative trait-based stereotypes in making social judg- ments. As in the neighborly interaction, we consider additional and more positive trait information such as reliable or dependable. The volunteer position may be perceived as a context that older adults would be effec- tive regardless of their memory competence. In fact, research is drawing on these findings to identify what types of social environments will facilitate older adults’ social competence. We examine this later.
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220 CHAPTER 8
Activation of Stereotypes From the preceding review of research we know stereo- types of older adults exist regarding personality traits and perceptions of competence. They also influence our judgments about how capable older adults will be in memory-demanding situations. However, it is not enough to know the stereotypes exist; we need to know under what conditions they are activated, and if acti- vated, how they affect our behavior and social judg- ments. Why do negative stereotypes of older adults influence our behaviors (e.g., talking down to older adults as if they were children) and attitudes (Hehman et al., 2012)? Considerable research in social cognition focuses on stereotype activation as a relatively uncon- scious and automatic process that guides our behavior and social judgments (e.g., Kunda & Spencer, 2003; Yen, Jewell, & Hu, 2013).
Social psychologists suggest the reason stereo- types are automatically activated is they become over- learned and thus are spontaneously activated when we encounter a member or members of a stereotyped group, such as African American or Muslim (Stojnov, 2013). The activation of strong stereotypes, called implicit stereotyping , is not only automatic but also unconscious. Thus it is more likely they influence our behavior without our being aware of it.
The effects of such implicit stereotyping are illus- trated in a clever and classic study conducted by John Bargh and colleagues (Bargh et al., 1996). They dem- onstrated if you subliminally (outside of conscious awareness) prime young people with the image of an elderly person, the young people’s actual behavior is influenced in an age-related manner (where age- related refers to the target person’s age). In this case, the implicitly primed young adults walked down the hall more slowly after the experiment than did young adults who were not primed with the elderly image. This is a powerful demonstration of how our unconscious stereotypes of aging can influence our behavior.
Measuring implicit aging stereotyping is a chal- lenge because by definition it is inaccessible. How- ever, research using a technique called the Young-Old Implicit Attitudes Test (Crisp & Turner, 2012; Hum- mert et al., 2002) overcame this challenge. In this test, individuals categorize photographs of faces by
indicating as fast as they can whether the photo is a younger or older person. They are asked to press a but- ton with their right hand to indicate young and with their left hand to indicate old. Then they categorize other photographs as pleasant or unpleasant with the right hand indicating pleasant and the left hand indi- cating unpleasant. Next is the two-part test of implicit aging stereotypes. Part one consists of a combination of the young-old and pleasant-unpleasant categoriza- tion task using the same hands as just indicated. In this test, the right hand is associated with both young and pleasant, whereas the left hand is associated with both old and unpleasant. The second part reverses the hands for young-old. Now the right hand is associated with old and the left hand is associated with young. The right hand is still associated with pleasant, and the left hand with unpleasant. The logic is this: If you have a negative stereotype regarding aging, you will be much slower in your response during the second test.
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SOCIAL COGNITION 221
It becomes difficult to use your right hand to indicate old because it is also associated with pleasant. This dif- ficulty slows your response down.
Using this methodology, researchers (e.g., Crisp & Turner, 2012; Hummert et al., 2002) found people of all ages were faster to respond to young-pleasant and old-unpleasant trials than to old-pleasant and young- unpleasant trials. Furthermore, all individuals had implicit age attitudes that strongly favored the young over the old. If you would like to experiment with this test, it is available on the Internet.
Implicit stereotyping is illustrated in different domains of our behavior toward others as well. In many situations nursing staff or younger adults in general are trying to instruct or communicate with older adults, as seen in the photo. Much evidence suggests younger people engage in patronizing talk toward older adults in these situations (Hehman et al., 2012). As we saw in Chapter 5 , patronizing speech can be detrimental to old adults’ well-being.
Why do people engage in patronizing speech? Again, implicit stereotyping may be the answer. When communicating to others, we try to accommodate our audience so they understand what we are trying to say. In this case, when communicating to an older adult, negative stereotypes of older adults as less competent, less able to hear, and having poor memories may be activated and unconsciously and inadvertently result in an inaccurate assessment of how to accommodate our speech (see Chapter 5 ).
Stereotype Threat Another important question to ask is whether implicit negative stereotypes of aging influence the cognitive functioning of older adults. This possibility is raised in the context of widely cited social psychological research on stereotype threat. Stereotype threat is an evoked fear of being judged in accordance with a nega- tive stereotype about a group to which you belong. For example, if you are a member of a socially stigmatized group such as Latinos or Muslims, you are vulnerable to cues in your environment that activate stereotype threat about academic ability. In turn, you may per- form more poorly on a task associated with that ste- reotype regardless of high competence in academic settings.
Substantial attention has focused on understand- ing the harmful effects of negative aging stereotypes on memory performance in older adults (Levy, Zonder- man, Slade, & Ferrucci, 2012). Do older adults belong to a stigmatized group that is vulnerable to stereotype threat? Some researchers suggested that negative ste- reotypes do adversely affect older adults’ cognitive functioning and may contribute to our perception of age-related decline in cognitive functioning (see Chapter 6 ). The initial studies examining this possibil- ity used techniques similar to our discussion of stereo- type activation: assessing implicit stereotyping. Becca Levy’s nearly two decades of research has caused some controversy in this area. Read the Current Controver- sies feature. What do you think?
CURRENT CONTROVERSIES: ARE STEREOTYPES OF AGING ASSOCIATED WITH LOWER COGNITIVE PERFORMANCE? A major controversial issue in the cognitive aging lit- erature is whether living in a society that equates old age with memory decline, senility, and dependency produces what Langer (1989) calls a “premature cogni- tive commitment” early in life. As children, we acquire ideas of what it means to be old, ideas that are usually negative, that become stereotypes guiding and influ- encing our behavior later in life. Thus, the question is the degree that negative societal beliefs, attitudes, and expectations determine the cognitive decline we observe in older adults.
When Levy and Langer (1994) first compared memory performance and attitudes on aging of Chi- nese older adults, hearing American older adults, and deaf American older adults, they found the Chinese older adults outperformed both groups of American older adults on several memory tasks. In addition, the deaf American older adults outperformed their hearing American counterparts. Attitudes on aging held by the different cultures were related to memory performance (Chinese had more positive attitudes, whereas Ameri- cans had more negative attitudes). Levy and Langer concluded negative stereotypes in American culture accounted for this difference.
However, there were several concerns with this cor- relational study. Does enhanced memory performance lead to more positive attitudes, or do positive attitudes
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222 CHAPTER 8
There is also evidence middle-aged adults are susceptible to negative age stereotypes (O’Brien & Hummert, 2006). Middle-aged adults who identified with older adulthood showed poorer memory perfor- mance if they were told their performance would be compared with other older adults. Middle-aged adults with more youthful identities did not show differences in memory performance regardless of whether they were told they would be compared to younger or older individuals.
Although most of the research in this area focused on the detrimental effects of negative stereotypes, some evidence also exists for the beneficial effects of positive stereotypes on older adults’ cognitive perfor- mance. Compared to Milanese, Sardinians hold more positive attitudes about memory aging and perform better on memory tasks (Cavallini, Bottirolli, Fastame, & Hertzog, 2013).
The influence of stereotypes on performance is not restricted to just memory. Levy and Leifheit-Lim- son (2009) found subliminally inducing physical nega- tive aging stereotypes had a harmful effect on older adults’ balance performance. In contrast, presenting older adults with positive physical aging stereotypes resulted in better balance performance. Similarly, Levy and colleagues (2000) found that older adults exposed to negative aging stereotypes showed a heightened car- diovascular response to a stressful situation compared
to older adults exposed to positive aging stereotypes. Levy argues negative aging stereotypes can be viewed as direct stressors.
Positive aging stereotypes, in contrast, could potentially have the ability to reduce cardiovascular stress. Finally, Levy, Slade, and Kasl (2002) found in a longitudinal study older adults who maintained positive perceptions of themselves as aging individu- als tended to be healthier over time than those who held a negative self-perception of aging. Similarly, Jeste, Savla, Thompson, Vahia, Glorioso, Martin and colleagues (2013) report the stereotype of aging may be changing. It was the oldest-old who had the most positive view of successful aging. Thus it is important to recognize the role of positive stereotypes on older adults. Remember, however, this is correlational data. It does not tell us whether positive stereotypes cause people to be healthy across their adult life span. Nev- ertheless, the findings discussed here demonstrate how pervasive and powerful stereotypes can be on our behavior.
lead to enhanced memory performance? Are there edu- cational differences between the two cultural groups? Are the memory tests really the same given that they had to be translated into Chinese?
To further test this notion, Levy (1996) sublimi- nally primed younger and older adults with negative stereotypes of an older adult (e.g., the word senile ) or positive stereotypes (e.g., the word wise ). She found when older adults were primed with negative aging stereotypes, their performance was worse on memory tests than older adults primed with positive stereo- types. Other researchers confirmed this result (e.g., Stein, Blanchard-Fields, & Hertzog, 2002; von Hippel & Henry, 2012).
Levy’s most important and controversial finding goes well beyond results from laboratory task results in a one-time testing experience. She and her colleagues (Levy et al., 2012) showed adults over age 60 with more
negative age stereotypes demonstrated over 30 % greater decline in memory performance over 38 years than those with fewer negative age stereotypes.
It is intriguing and intuitive to believe a self- fulfilling prophecy operates with respect to older adults’ memory performance. If society portrays older adults as declining in cognitive capacity and you are socialized to believe so at a young age, and if you believe these stereotypes, then it makes sense this will influence your memory performance as an older adult. All in all, negative stereotypes of aging exist. They have an effect on cognitive performance. Thus, although you may not be able to eliminate the decline in performance, interventions for improving attitudes and outlook on aging have the potential to improve the quality of performance relative to one’s own level of functioning (Cherry, Brigman, Reese-Melancon, Burton-Chase, & Holland, 2013).
Adult Development in Action How would knowledge about the effects of negative stereotypes on older adult’s cognition affect your approach to assessing them in a healthcare setting?
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SOCIAL COGNITION 223
8.2 Social Knowledge Structures and Beliefs LEARNING OBJECTIVES
What are social knowledge structures? What are social beliefs, and how do they change
with age? What are self-perceptions of aging, and what
influences them across adulthood?
Anna is going on her first date since the death of her husband one year ago. She is 62 years old and was mar- ried for 30 years, so she is extremely nervous about what to do and how to act. When her date, Eric, picks her up, he announces he has made reservations at a nice Italian restaurant and afterward they will go to a late movie. Although Anna is nervous, she makes it through the date with few problems. To her delight, how she needs to act and what she should do came flooding back to her with- out an ounce of effort.
Similar to our knowledge of how a supervisor should act, on her date Anna experienced the easy accessibility of a well-learned social script or social knowledge on how to behave on a date. Social cogni- tive research has paid considerable attention to how social knowledge structures and social beliefs guide behavior.
Social knowledge structures and social beliefs are defined in terms of how we represent and interpret the behavior of others in a social situation (Frith & Frith, 2012). They come in many different forms. We have scripted knowledge structures regarding everyday activities such as what people should do when they go to the doctor’s office or a restaurant. We are social- ized to adhere to and believe in social rules, or how to behave in specific social situations, such as how a husband should act toward his wife.
Understanding Age Differences in Social Beliefs
Two interesting developmental questions arise with respect to social knowledge structures. First, does the content of our social knowledge and beliefs change as we grow older? And second, how do our knowledge structures and beliefs affect our social judgments, memory, problem solving, and more?
There are many types of belief systems that differ in content across age groups and also influ- ence behavior. Understanding age differences in social belief systems has three important aspects (Blanchard-Fields & Hertzog, 2000; Blanchard-Fields et al., 2012; Blanchard-Fields & Horhota, 2006). First, we examine the specific content of social beliefs (i.e., the particular beliefs and knowledge individuals hold about rules, norms, and patterns of social behavior). Second, we consider the strength of these beliefs to know under what conditions they may influence behavior. Third, we need to know the likelihood these beliefs are automatically activated when a person is confronted with a situation when these beliefs are being violated or questioned. If these three aspects of the belief system are understood, it is possible to explain when and why age differences occur in social judgments.
Older adults may hold different beliefs than other age groups (e.g., different rules for appropri- ate social behavior during Anna’s situation of dating). Such differences may stem from cohort differences (see Chapter 1 ). Additionally, how strongly individu- als hold these beliefs may vary as a function of how particular generations were socialized. Although younger and older generations may both believe peo- ple should not live together before marriage, the old- est generation may be more adamant and rigid about this belief. However, evidence of age differences in the content of social beliefs does not provide a suf- ficient basis for understanding age differences in how and when such beliefs are activated and how they influence behavior.
Social cognition researchers argue there are individual differences in the strength of social rep- resentations of rules, beliefs, and attitudes linked to specific situations (Frith & Frith, 2012). Such repre- sentations can be both cognitive (how we conceptu- alize the situation) and emotional (how we react to the situation). When encountering a specific situa- tion, the individual’s belief system predictably trig- gers an emotional reaction and related goals tied to the content of that situation. This in turn drives social judgments.
Let’s take the rule “You should never live with a romantic partner before you are married.” If you
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224 CHAPTER 8
were socialized from childhood to believe in this rule, you would negatively evaluate anyone violat- ing it. If you were told Allen was putting pressure on Joan to live with him before they were married, and they subsequently broke up, you might have a negative emotional response and blame Allen for the breakup of the relationship because he was lobbying for cohabitation.
In a series of classic studies exploring social beliefs, age differences were found in the types of social rules evoked in different types of situations (Blanchard-Fields, 1996, 1999). Consider the situation we encountered in Chapter 7 about the influence of social rules on cognition (see page 204 ) in a situation that a husband chooses to work long hours instead of spending more time with his wife and family. As we saw in Figure 7.5, adults of different ages invoke the social rule “Marriage is more important than a career” more with increasing age. This was particularly evi- dent from age 24 to age 65 . Figure 7.5 also shows the social rule “The marriage was already in trouble” has an inverted U-shaped relationship. In other words, adults around ages 35 to 55 years as compared to 24 - to 35 -year-olds and those over 65 years produced this social rule the most.
In the present context, these findings indicate the influence of cohort effects on how different generations were socialized with respect to the important social rules of marriage. The oldest generation was probably socialized differently from the current younger adult generation as to what is appropriate behavior on the part of husbands and wives.
Alternatively, viewing marriage as more important than one’s career may relate to the particular life stage and life circumstances different age groups confront rather than cohort differences. In this view, irrespec- tive of cohort, making a living and proving oneself in a career may take precedence during mid-career/mid- family stages (Schaie, 1977–1978). In contrast, during the retirement/empty nest phase, the importance of a marital relationship may reemerge.
Still another interpretation might be the middle- aged group may not have relied on social rules to guide their thinking about the problem situation and focused more on the marital conflict itself. This could possibly reflect a by-product of the 1960s focus on communica- tion of feelings. These are only a few examples of the
complex sociocultural experiential factors that may influence different social beliefs.
Let’s consider another scenario, this time involving a youthful couple who eloped despite the objections of their parents. The social rules “Parents should have talked to, not provoked, the young couple” and “They were too young” also displayed an inverted U-shaped relationship with age. Middle-aged individuals endorsed these rules, whereas younger and older age groups did not.
In contrast, the social rule “You can’t stop true love” displayed a U-shaped relationship with age. Younger and older age groups endorsed this rule whereas individuals in middle adulthood did not. It may be the case in middle adulthood, between the ages 30 and 45 , people are not focusing on issues of “Love conquers all.” This makes sense given they are in the stage of life where the pragmatic aspects of building a career are more important than the passion of love. Middle-aged adults also emphasized the pragmatics of age (e.g., being too young) as an important factor in marriage decisions.
In summary, how social rules are invoked in mak- ing social judgments is a complex process. To some extent, the process reflects generational differences, and it reflects life experience. How these judgments influence our judgments about personal responsibility for behavior is a topic we turn to next.
Self-Perception and Social Beliefs An important facet for understanding the impact of social beliefs on people is to understand how we form impressions of ourselves. It’s our personal answer to the question, “How old do you feel?” that creates our self- perception of aging. Self-perception of aging refers to individuals’ perceptions of their own age and aging.
Researchers have been curious about how people see themselves on this dimension for many years. In Chapter 14 , how we view ourselves is an important predictor of whether we age successfully (or not). We know that positive self-perceptions are correlated with many good outcomes, such as better well-being, better health, and longer life (Kotter-Grühn & Hess, 2012).
Without doubt, what we think is true about the process of aging affects what we think of ourselves. The social stereotypes we associate with aging influ- ence what we believe is true about us.
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SOCIAL COGNITION 225
There are two major frameworks to explain how this influence works. Labeling theory argues when we confront an age-related stereotype, older adults are more likely to integrate it into their self-perception. Research on impression formation and priming of stereotypes supports this view. Resilience theory argues confronting a negative stereotype results in a rejection of that view in favor of a more positive self- perception. This view comes from people’s tendency to want to distance themselves from the negative stereotype. Research shows older adults dissoci- ate themselves from their age group when negative stereotypes become relevant to them (e.g., Weiss & Lang, 2012).
A good example of this line of research is highlighted in the How Do We Know? feature. Kotter-Grühn and Hess (2012) studied how negative views of aging were or were not assimilated into adults’ views of themselves.
What’s so different about self-perceptions of age and aging is it is one of the few areas we go
from looking at old people and aging as something that happens to someone else rather than something happening to us (Kornadt & Rothermund, 2012). Research on how we incorporate societal views of age and aging indicate the extent to which that happens depends critically on our own old age and aging in specific domains of life (e.g., health). When we con- sider the influence stereotypes have on our thinking, we return to the ways self-perception affects how well we do things like remember information and even our health and longevity.
HOW DO WE KNOW?: AGE DIFFERENCES IN SELF-PERCEPTION Who were the investigators and what was the aim of the study? Kotter-Grühn and Hess (2012) knew people’s self-perceptions are important predictors of well-being and health. They wanted to find out what the specific indicators of self-perceptions of aging across adulthood are, and whether specific stereotypes about aging influ- enced self-perceptions.
How did the investigators measure the topic of interest? Personal satisfaction with aging was measured through a well-researched scale, the Philadelphia Geri- atric Center Morale Scale. Respondents also indicated their “felt age,” “desired age,” and “perceived age.” Physical health was assessed by a health survey. Age- related stereotypes were activated through a priming approach of rating faces described with either positive, negative, or neutral terms.
Who were the participants in the study? 183 adults aged 18 – 92 years volunteered to participate. There were 60 younger adults, 62 middle-aged adults, and 61 older adults. Overall, participants averaged over 14 years of education, and were paid $ 15 /hour.
Were there ethical concerns with the study? Because the study used volunteers and were provided informed consent, there were no ethical concerns.
What were the results? As participant age increased, participants increasingly indicated they felt, wanted to be, and believed they looked proportionally younger than their actual age. Younger adults wanted to be about 4 % older than they actually were, and older adults wanted to be about 33 % younger than they were.
Following the priming task, older adults were the only age group to feel older regardless of whether the priming was positive or negative. For desired age, participants in all age groups who were in bad health reported they wanted to be a younger age after experi- encing the negative priming task (but no change other- wise). For perceived age, all participants in poor health reported themselves as looking older after receiving the negative priming task.
All adults reported being relatively satisfied with their aging process.
What did the investigators conclude? Kotter-Grühn and Hess concluded that people’s perceptions of their own aging are not made more positive by presenting them with positive images of aging. Actually, the oppo- site effect occurred for younger and middle-aged adults in good health—when given positive stereotypes, those groups reported feeling older than before the priming task. Their conclusion was negative images of aging have more powerful effects than positive ones in deter- mining self-perceptions of aging.
Adult Development in Action If you are a taking a poll on attitudes toward spe- cific social issues, how would you design the survey to uncover the reasons for any age differences that were found?
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226 CHAPTER 8
8.3 Social Judgment Processes LEARNING OBJECTIVES
What is the negativity bias in impression formation, and how does it influence older adults’ thinking?
Are there age differences in accessibility of social information?
How does processing context influence social judgments?
To what extent do processing capacity limitations influence social judgments in older adults?
Alexandra and Klaus were taking care of their grandchil- dren for the weekend. They took them to the zoo for an outing. When they passed the gift shop, the children would not stop whining that they wanted a present. This frustrated Alexandra and Klaus, and they both tried to come up with an explanation for this distressing behavior. At first, they were worried because it seemed the behavior of their grand- children indicated they were, in essence, selfish children. But on further reflection, they considered other factors. The par- ents always bought the children a gift at the zoo, and so the children naturally expected it to happen again. The grand- parents felt better about the situation after considering the parents’ role in it and bought the gifts for the children.
In this situation, Alexandra and Klaus were mak- ing important social judgments. They carefully ana- lyzed the situation to understand their grandchildren’s behavior by focusing on all the factors involved in it. Alexandra and Klaus show how we can correct our ini- tial assessments of others if we take the time to reflect about all of the extenuating circumstances.
But what would have happened if they did not have the time to think about it, and instead had mul- tiple distractions, such as dealing with the emotional outbursts of their grandchildren as well as their own emotional reactions? Their judgments could also have been influenced by strong beliefs about how children should behave in a social situation such as this one.
We consider the influence of both of these factors on making social judgments: the role played by cogni- tive capacity, or having enough time and making the effort to reflect on a situation, and social knowledge and beliefs. However, first let us explore the age differ- ences in making social judgments.
Many laboratory studies examined abstract cog- nitive skills and how they change as we get older (see Chapter 6 ). Like the everyday cognition research dis- cussed in Chapter 7 , an important question in social cognition research is: to what extent do the findings from the lab translate into understanding behav- ior in everyday contexts as people grow older? The social cognition perspective provides a way of exam- ining how basic cognitive abilities operate in social situations. The basic goal of the social cognition approach is to understand how people make sense of themselves, others, and events in everyday life (Frith & Frith, 2012).
Impression Formation When people meet each other, we tend to immediately come to conclusions about them on many dimensions. Researchers (e.g., Adams, Nelson, Soto, Hess, & Kleck, 2012; Hess & Emery, 2012) examine age differences in social judgments by examining impression formation. Impression formation is the way we form and revise first impressions about others. Researchers examine how people use diagnostic trait information (aspects about people that appear critical or unique) in mak- ing initial impressions of an individual, and how this process varies with age. A common way of studying this is to have two groups of adults presented with information about a person, either through descrip- tions or inferences. One group gets positive informa- tion first, such as evidence of honesty. The other group is presented with negative information first, such as incidents of dishonest behavior. Each group then subsequently gets the opposite information about the
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SOCIAL COGNITION 227
person (e.g., the group that got positive information first then gets negative information).
What happens to people’s first impressions as a function of age is a well-established finding. As you can see from Figure 8.1 , in a study that helped create this area of research focus, Hess and Pullen (1994) found all study participants modified their impressions. When
new negative information was presented after the initial positive portrayal of the target person, older adults modified their impression of the target from positive to negative. Interestingly, however, they modified their first impression less when the negative portrayal was followed by positive information. Older adults make impressions influenced by all the information they receive.
Figure 8.1 Mean trait ratings before and after presentation of new negative or positive information. Source: A modified graph of the Hess, T. M., & Pullen, S. M. (1994). Adult age differences in impression change processes. Psychology and Aging 9, p. 239.
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228 CHAPTER 8
In contrast, younger adults did not show this pattern. Instead, they were more concerned with mak- ing sure the new information was consistent with their initial impression. To do so, they modified their impressions to correspond with the new informa- tion regardless of whether it was positive or negative. Younger adults, then, make their impression based on the most recent information they have.
Why do younger and older adults differ? Hess and Pullen suggest older adults may rely more on life expe- riences and social rules of behavior when making their interpretations, whereas younger adults may be more concerned with situational consistency of the new infor- mation presented. They also suggest older adults may be more subject to a negativity bias in impression forma- tion. Negativity bias occurs when people allow their initial negative impressions to stand despite subsequent positive information because negative information was more strik- ing to them and thus affected them more strongly.
This bias corresponds well with other studies dem- onstrating older adults pay attention to and seek out emotional information more than do younger people (Isaacowitz & Blanchard-Fields, 2012; von Hippel & Henry, 2012). We discuss this further later in the chap- ter. This bias suggests decline in cognitive functioning limits the ability of older adults to override the impact of their initial impressions.
Further evidence shows the social judgments older adults make appear to be more sensitive to the diag- nosticity of the available information (Hess, 2006). If young adults receive new information about a per- son that contradicts their original impression, they are likely to adjust the initial impression. However, older adults are more selective in the information they choose to use in forming their judgments. They focus more on the relevant details to make those judgments, and change their initial impression only if the new information is diagnostic , that is relevant and informa- tive (Hess & Emery, 2012; Hess, Germain, Rosenberg, Leclerc, & Hodges, 2005). It appears for older adults to invest information-processing resources in making a judgment, they need to be invested in the social situ- ation that the judgment is made.
In some situations, older adults may be at a disad- vantage when processing social information. Research- ers have found although younger and older adults can
process social information similarly, older adults are at a disadvantage when the social context is cognitively demanding (Hess & Emery, 2012; von Hippel & Henry, 2012). A cognitively demanding situation is similar to Alexandra and Klaus’s situation where they were try- ing to understand their grandchildren’s behavior under conditions of time pressure and multiple distractions. Researchers find when older adults take their time to make a social judgment, they process information similarly to younger adults and take into consideration all of the relevant information. However, when given a time limit, they have difficulty remembering the information they need to make their social judgments (Ybarra & Park, 2002; Ybarra, Winkielman, Yeh, Burn- stein, & Kavanagh, 2011).
In the next section, we examine processes involved in accessing knowledge used to make social judgments.
Knowledge Accessibility and Social Judgments
Although we make judgments about people upon ini- tial meeting and novel situations all the time, we tend not to be aware of exactly how those judgments are made. When we are faced with new situations, we draw on our previous experiences stored in memory, in other words, our social knowledge .
The stored knowledge about previous situations that might be similar and how easily we can retrieve it, affects what types of social judgments we make and how we behave in social situations. If you are attend- ing your first day of work, for example, in order to act appropriately you draw on social knowledge that tells you “how to behave in a job setting.” This process includes having available stored representations of the social world or memories of past events, how to apply those memories to various situations, and easy access to the memories.
We draw on implicit theories of personality (our personal theories of how personality works) to make judgments. For example, how a supervisor should behave at work. If the supervisor’s behavior is incon- sistent with our implicit theory of how he or she should act, this affects the impression we form of the supervisor. If a supervisor dresses in shorts and T-shirt and makes casual references to the party he attended last night, this may violate our implicit theory
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SOCIAL COGNITION 229
that supervisors should dress and act professionally. Research supports that implicit personality theories we have about people, in general, influence the impres- sions we form about specific individuals (Uleman & Saribay, 2012; von Hippel & Henry, 2012).
However, the fact social information in memory is available does not necessarily imply it is always easy to access to the information. The degree to which infor- mation in memory is easily accessible and remem- bered determines the extent that information will guide social judgments and/or behavior.
As we saw in Chapter 7 , easy access to information will be influenced by several variables. First, acces- sibility depends on the strength of the information stored in memory. If you have extensive past experi- ence with people who are aggressive, retrieving and applying the specific personality trait “aggressive,” will be a highly accessible social knowledge structure rep- resenting features of this particular personality trait (e.g., dominance in social situations, highly competi- tive, and so on). Thus, you would judge a person as “aggressive” by interpreting the collection of behaviors you associate with “aggressive” as clearly diagnostic of aggressiveness.
In contrast, the personality trait construct “aggres- sive” would not be easily accessible for people who have little or no experience with aggressive people because the trait of aggressiveness may not have been retrieved often. These people would be likely to interpret the behavior differently (Uleman & Saribay, 2012). They may see the dominant or aggressive behavior a person exhibits as indicative of positive leadership.
Age differences in the accessibility of social knowl- edge influence social judgments across adulthood. First, as we saw in the case of impression formation, older adults rely on easily accessible social knowledge structures such as the initial impression made about an individual. Second, age differences in knowledge acces- sibility also depend on the extent people rely on source judgments , in other words, when they try to determine the source of a particular piece of information. Suppose you and a friend were introduced to two new people last week. Jane is an athlete and Sereatha is a bookworm. Sereatha revealed to you she loves to play tennis. Today, your friend asks you whether it was Jane or Sereatha that loves to play tennis. This is a source judgment.
Mather and colleagues (Mather, 2012; Nashiro, Sakaki, Huffman, & Mather, 2013) found when making source judgments, older adults rely more on easily acces- sible knowledge than younger adults. In the example of meeting Jane and Sereatha, older adults would be more likely to erroneously remember Jane loves to play tennis, as they would rely on an easily accessible stereotype the athlete is more likely to love tennis than the bookworm.
Finally, older adults make more social judg- ment biases because they have trouble distinguish- ing between true and false information (Chen, 2002; Wang & Chen, 2006). In studies by Chen and col- leagues, older adults were instructed to disregard false information (printed in red) and pay attention to true information (printed in black) when reading criminal reports. The older adults had difficulty in doing so, and the false information (e.g., information exacerbating the nature of the crime) biased their judgments about how dangerous the criminal was and this affected their determination of the criminal’s prison sentence.
Neuroimaging research indicates damage to or age-related changes in certain parts of the prefrontal cortex may be responsible for increased susceptibil- ity to false information (Asp, Manzel, Koestner, Cole, Denburg, & Tranel, 2012). Therefore, there may be an age-related neurological reason why older adults are more likely to believe misleading information, such as that used in advertising or political campaigns.
A Processing Capacity Explanation for Age Differences in Social Judgments
Based on the research discussed so far, it appears pro- cessing resource limitations play an important role in understanding how older adults process and access social information. In fact, social cognitive research- ers have long used information-processing models to describe how individuals make social judgments. In one of the best known models, Gilbert and Malone (1995) established the ability to make unbiased social judgments depends on the cognitive demand accom- panying those judgments. We all make snap initial judgments, but then we reconsider and evaluate pos- sible extenuating circumstances to revise those judg- ments. This revision takes processing resources, and if we are busy thinking about something else we may not be able to revise our initial judgments.
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230 CHAPTER 8
As we consider in more depth in the section on causal attributions, Blanchard-Fields and colleagues (Blanchard-Fields & Beatty, 2005; Blanchard-Fields, Hertzog, & Horhota, 2012) found older adults consis- tently hold to their initial judgments or conclusions of why negative events occur more often than younger adults. They appear not to adjust their initial judg- ments by considering other factors, as Alexandra and Klaus were able to do when they revised their interpre- tation of their grandchildren’s behavior.
Because older adults typically exhibit lower levels of cognitive processing resources (see Chapter 6 ), it is possible this decline in resource capacity might impact social judgment processes. In the case of impression formation, older adults may have limited cognitive resources to process detailed information presented after the initial impression is formed. Use of such information overworks processing resources. Simi- larly, source judgments and selectively attending to only true information also places demands on one’s cognitive resources.
If processing resource capacity is the major fac- tor explaining social judgment biases, then it should affect all types of situations older people encounter. However, it also may be the extent social information is accessible, operates independently of a processing resource limitation to influence social judgments.
Attributional Biases Consider the following scenario:
Erin is cleaning up after her infant son who spilled his din- ner all over the table and floor. At the same time, she is lis- tening on the phone to her coworker, Brittany, describing how anxious she was when she gave the marketing presentation in front of their new clients that day. Brittany is also describ- ing how her supervisor told her the company depended on this presentation to obtain a contract from the new clients. After the phone call, Erin reflected on Brittany’s situation. She decided Brittany is an anxious person and should work on reducing her anxiety in these types of situations.
Erin was interested in what caused Brittany’s anxi- ety when presenting information at work. Was it some- thing about Brittany, such as being an anxious person? Or was it due to some other reason, such as luck or chance? Or was it because of the pressure placed on Brittany by her supervisor?
Answers to these questions provide insights into particular types of social judgments people make to explain their behavior that are referred to as causal attributions. Causal attributions are explanations of why behaviors occur. A dispositional attribution is a causal attribution that concludes the cause resides within the actor. An explanation such as “Brittany is just an anxious person” would be a dispositional attribution of why Brittany is nervous. A situational attribution is an explanation that the cause resides outside the actor. An explanation such as “Brittany is succumbing to pres- sures from her supervisor and that’s why she’s nervous” would be a situational attribution.
In this vignette, Erin made a dispositional attribu- tion about Brittany. In this section, we explore if there are age differences in the tendency to rely more on dis- positional attributions, situational attributions, or on a combination of both when making causal attributions.
Historically, the study of attributions and aging has been confined to studying attributional judgments made about the aging population, usually involving competence in some domain such as memory. We discuss these issues when we examine research on stereotypes and attributions about older adults’ men- tal competence. In that case, attributions about older persons’ successes and failures are compared to similar successes and failures of younger adults. Such attribu- tions go hand-in-hand with the stereotyping of older adults.
However, more recently the focus in attribu- tion and aging research turned to the examination of changes in the nature of attributional processes, per se, from an adult developmental context. Thus, the ques- tion can be asked whether findings typically discovered in social psychological attribution theory and research hold true beyond the college years (Blanchard-Fields et al., 2008).
For many years, we have known college students typically produce informational distortions when mak- ing causal attributions about problem solving, called correspondence bias (e.g., Gilbert & Malone, 1995). In this case, youth rely more on dispositional information in explaining behavior and ignore compelling situa- tional information such as extenuating circumstances.
Suppose you tried to approach your psychology professor yesterday. She did not acknowledge you were there but kept walking with her face buried in a
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SOCIAL COGNITION 231
manuscript. You might decide because your professor ignored your question, she is arrogant (a dispositional attribution). At the same time, you may have ignored important situational information, such as if she has recently been overwhelmed by upcoming deadlines. Thus you did not consider all the pertinent informa- tion to make a more accurate judgment. This type of finding has been primarily documented with college youths. However, it may be the case the life experience accumulated by middle-aged and older adults causes them to reach different conclusions and they consider equally both types of information in explaining why things happen the way they do.
In a series of creative investigations, Blanchard- Fields (Blanchard-Fields & Beatty, 2005; Blanchard- Fields & Horhota, 2005; Blanchard-Fields et al., 2007; Blanchard-Fields et al., 2012) studied the differences in causal attributions across the adult life span. Blanchard- Fields presented participants with different situations having positive or negative outcomes and asked them to decide whether something about the main charac- ter in the story (dispositional attributions), the situ- ation (situational attributions), or a combination of both (interactive attributions) was responsible for the event. The vignettes represented situations such as that described earlier where Allen was pressuring Joan to live with him before marriage, Joan protested but Allen continued to pressure her, and the relationship ended up falling apart.
When the target events were ambiguous as to what was the specific cause of the outcome, as with Allen and Joan, all adults tended to make interactive attribu- tions, but older adults did so at a higher rate. However, as can be seen from Figure 8.2 , older adults paradoxi- cally also blamed the main character more (disposi- tional attributions) than younger groups, especially in negative relationship situations.
In her research, Blanchard-Fields took a sociocul- tural perspective in explaining why older adults were more predisposed to making dispositional attribu- tions and engaged in less postformal/dialectical rea- soning in negative relationship situations. She notes the correspondence bias in older adults only occurred in negative relationship situations. In this case, older adults appeared to apply specific social rules about relationships in making their attributional judg- ments, apparently because of their stage in life and the
cohort in which they were socialized (such as the rule “ Marriage comes before career”). In these situations, strong beliefs about how one should act in relation- ship situations appeared to be violated for the older adults, particularly older women. Therefore, these women made snap judgments about the main char- acter that violated their strong beliefs and did not feel it was necessary to engage in conscious, deliberate analyses. They knew the character was wrong, as in the husband who chose to work long hours and not spend time with his family.
The interesting question arises, however, as to whether these attributional biases in older adults are truly due to activated belief systems that strongly impact their judgments or whether the older adults are deficient in conducting a causal analysis. This deficiency could take the form of limited cognitive resources that might prevent them from processing all details of the situation (e.g., extenuating situational circumstances). The vignette involving Erin shows how, on the one hand, we can rely on our experience as older adults to guide us through uncomfortable situations; but on the other hand, a reduction in our capacity does not allow us to consider all the relevant information in this case to make an accurate judgment about Brittany’s behavior.
Figure 8.2 Dispositional attributions as a function of age. © Cengage Learning
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232 CHAPTER 8
8.4 Motivation and Social Processing Goals LEARNING OBJECTIVES
How do goals influence the way we process information, and how does this change with age?
How do emotions influence the way we process information, and how does this change with age?
How does a need for closure influence the way we process information, and how does it change with age?
Tracy and Eric are visiting their children and all their grandchildren on Cape Cod. All are having a good time until their son, Eddie, brings up the hot topic of the upcoming presidential election. The debate between family members regarding the best candidate becomes heated. Tracy and Eric are concerned about the negative feelings generated in the debate and encourage everyone to change the topic. However, the brothers and sisters are more interested in settling the issue now rather than later. Tracy and Eric cannot handle the negative energy and retire to bed early.
Why did Tracy and Eric focus on the emotional side of the problem (the increase in negative feelings), whereas the siblings focused on the more instrumental side of the problem (e.g., whom to vote for)?
The different foci of Tracy and Eric in contrast to the children resulted in different problem-solving strategies. Much like the research on social rules and social judgments, there is a growing area of research suggesting change in the relative importance of social goals and motivation across the life span profoundly influence how we interpret and use social information or direct attention and effort to certain aspects of the problem situation (Hess, 2006).
Earlier we questioned whether a processing resource hypothesis was the best explanation of social judgment biases. Again, this is particularly impor- tant because in Blanchard-Fields’s attribution studies, the dispositional bias was only found for older adults when they were presented with negative relationship situations. Researchers have found everyday reason- ing biases in older adults occur not because of declin- ing cognitive ability, but because older adults are more likely than younger adults to base their judgments on their own beliefs (Blanchard-Fields et al., 2012; Klaczynski and Robinson, 2000).
These findings indicate the explanations people create to account for behavior vary depending on the type of situation (e.g., relationship or achievement situations), the age of the person, and whether strong social beliefs have been violated by a person in the situation. What is also emerging is the importance of the sociocultural context where people are socialized, since this appears to create different social rules that are then used to make causal attributions. Additional research supports this idea.
Blanchard-Fields and colleagues (2007) examined causal attributions in younger and older Chinese adults in comparison to younger and older American adults. Interestingly, they found older Americans showed a greater correspondence bias than younger Americans. However, both younger and older Chinese performed similarly and showed less correspondence bias. Older Americans may focus their attributions on the indi- vidual due to a lifelong experience of an individualistic orientation.
In order to adjust this initial judgment, the con- textual information must be made salient to them in a socially meaningful manner. Support for this idea comes from studies showing when there is a plausible motivation for the target’s behavior; older adults can correct their judgments to be less biased than in a stan- dard attitude attribution paradigm (Blanchard-Fields & Horhota, 2005).
For older Americans to correct their attributions, the constraint needs to provide a meaningful reason why a person would contradict his or her own beliefs. For Chinese older adults, the meaningful nature of the situation does not need to be emphasized because to them situational influences and constraints repre- sent a naturally occurring manner to approach any
judgment situation and they have a lifelong experience of a collectivist orientation. More research is needed to shed additional light on how these age differences are created and under what circumstances they appear.
Adult Development in Action How might older adults’ impression formation behav- ior be important to you as a political candidate?
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SOCIAL COGNITION 233
Goals change with age as a function of experience and time left in the life span. This can influence the degree we observe age differences in social cognitive functioning, such as the desire to focus on preserving ones’ resources or eliminating negative affect in prob- lem situations. Let’s explore these further.
Personal Goals Personal goals play a major role in creating direction in our lives. They consist of underlying motivations for our behavior and how we perceive our own ever- changing environment. Across the life span, personal goals change to match our needs, with young adults striving mainly for achievement, like completing a college degree or starting a career, and middle-aged and older adults seeking a balance between function- ing independently and sharing their lives with others (e.g., children, spouses).
Selective optimization with compensation (SOC; see Chapter 1 ) is an important theoretical model that suggests development occurs as we continuously update our personal goals to match our appraisal of available resources to obtain those goals (Baltes et al., 2006). We choose manageable goals based on our interests as well as physical and cognitive strengths and limitations. As we grow older our limitations become more salient and require us to reevaluate our interests. Therefore, in older adulthood, research suggests inter- ests shift toward physical health and socio-emotional domains (Carstensen & Mikels, 2005; Isaacowitz & Blanchard-Fields, 2012).
This shift in priorities means goals for the same event may be perceived differently by older and younger adults. An example of the shift in goal selec- tion can be seen in research that examines how younger and older adults prioritize how they want to perform in a dual-task situation. In a classic study, younger and older adults were asked to memorize a list of words while simultaneously maintaining their balance as they walked through an obstacle course (Li, Lindenberger, Freund, & Baltes, 2001). Although age differences in performing two tasks at the same time were more costly for the memory task than the walk- ing task, older adults chose to forgo aids to improve their memory (e.g., a list) and instead chose to use aids designed to optimize walking performance (e.g., a handrail). When deciding which was more important
to them, memory performance versus balance, older adults displayed a preference for their physical safety even if it meant they would perform badly on a cogni- tive test. From this example, we see life-span shifts in personal goals can be both helpful and harmful.
Goal selection requires we thoughtfully choose where we invest our resources. In the laboratory, younger adults are primarily motivated to achieve max- imum performance on any cognitive task presented to them. Older adults take a different perspective. They prefer to maintain steady performance by optimizing their current resources rather than risking loss with an unknown strategy (Baltes & Rudolph, 2012; Ebner, Freund, & Baltes, 2006).
Thus, although older adults are less willing than younger adults to invest energy into improving their cognitive performance, their strategy choice is more optimal for them because they are more interested in retaining their autonomy by maintaining abilities at their current level. Although this does not directly translate into cognitive gains, it does help older adults optimize their cognitive performance in those domains they prioritize in their lives (Baltes & Rudolph, 2012; Riediger, Freund, & Baltes, 2005). Although we can- not compensate for all of the resource limitations that come with advancing age, we can invest the resources we have into goals that maximize an independent life- style and a positive sense of well-being.
Along these lines, recent work by Carstensen and her colleagues suggests the pursuit of emotionally gratifying situations becomes a primary motivation that substantially influences cognition in the latter half of the life span (Carstensen & Mikels, 2005; Reed & Carstensen, 2012). We therefore turn to the impact of emotional processing goals on cognition.
Emotion as a Processing Goal Emotional goals become increasingly important and salient as we grow older (Carstensen & Fried, 2012). It is primarily a motivational model that posits the degree an individual construes time as limited or expansive that leads to the ranking of emotional or knowledge-seeking goals as higher in priority, respec- tively. Thus, given limited time left in the life span, older adults may be more motivated to emphasize emotional goals and aspects of life. We examine this motivational factor in the context of maintaining and
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234 CHAPTER 8
choosing intimate relationships in Chapter 10 . How- ever, it also can be applied in the context of social information processing.
A growing number of studies suggest older adults avoid negative information and focus more on positive information when making decisions and judgments and when remembering events, a phenomenon called the positivity effect (Carstensen & Fried, 2012; Carstensen, Mikels, & Mather, 2006). Older adults remember positive images more than negative ones, whereas younger adults remember both positive and negative images equally well (Isaacowitz & Blanchard-Fields, 2012; Reed & Carstensen, 2012). When examining what types of stimuli younger and older adults initially attend to, older adults allocate less attention to negative stimuli (e.g., angry faces) than younger adults. Older adults also remember more posi- tive information when recalling their own autobiographi- cal information and remember the positive aspects of their decisions more than the negative ones.
An alternative perspective proposes focusing on negative information is adaptive because it signals danger and vulnerability and thus is important for survival. This emphasis on negativity has been found in both the social and cognitive neuroscience litera- ture for many years (e.g., Lane & Nadel, 2000; Rozin & Royzman, 2001). Within the social cognitive aging literature, some studies demonstrate older adults spend more time viewing negative stimuli (Charles et al., 2003) and display a negativity effect (Thomas & Hasher, 2006; Wood & Kisley, 2006).
With respect to memory, Grühn and colleagues (2005) found no evidence for a positivity effect; instead they found evidence for reduced negativ- ity effect in older adults when remembering a list of words with negative, positive, and neutral valence. When incidentally encoding pictures, both younger and older adults recalled the central element more than peripheral elements for only negative scenes. However, when instructed to attend to this difference, only younger adults overcame this encoding bias, whereas older adults could not overcome the memory trade-off (Kensinger, Piguet, Krendl, & Corkin, 2005).
Emotional goals appear to help older adults because they create a supportive context for their cog- nitive functioning. In Chapter 6, we discussed the fact older adults create more false memories than younger adults do. Research on the interface between emotions
and cognition suggest the distinctiveness of emotions helps older adults reduce the number of false memo- ries produced (May, Rahhal, Berry, & Leighton, 2005; Sakaki, Niki, & Mather, 2012).
However, it is important to recognize there are times when emotions may impede information pro- cessing. For example, highly arousing situations require a great amount of executive control processing (discussed in Chapter 6 ) that may lead older adults to be poorer at remembering and processing informa- tion (Kensinger & Corkin, 2004; Reed & Carstensen, 2012). In addition, a focus on only positive informa- tion can interfere with decision making by leading older adults to miss out on important negative infor- mation necessary to make a quality decision (Reed & Carstensen, 2012).
Cognitive Style as a Processing Goal Another type of motivational goal that influences our thinking comes from our cognitive style , or how we approach solving problems. Examples include a need for closure and the inability to tolerate ambiguous situa- tions. People with a high need for closure prefer order and predictability, are uncomfortable with ambigu- ity, are closed-minded, and prefer quick and decisive answers (Bar-Tal, Shrira, & Keinan, 2013). Empirical research on this construct resulted in the development
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SOCIAL COGNITION 235
of well- validated questionnaires such as the Need for Closure Scale (Webster & Kruglanski, 1994) and the Per- sonal Need for Structure Scale (Thompson et al., 1992).
The question is whether cognitive resources or need for closure are implicated in biased judgments. As discussed earlier, situations that require substan- tial cognitive resources (i.e., require a lot of effort in cognitive processing such as processing information under time pressure) result in an increase in inaccu- racies and biases in how we represent social informa- tion. However, biased judgments can also be caused by motivational differences such as an increase in need for closure. In fact, research using Need for Closure instru- ments suggests a high need for closure and/or structure is related to attributional biases, the tendency to make stereotyped judgments, formation of spontaneous trait inferences, and the tendency to assimilate judgments to primed constructs (e.g., Bar-Tal et al., 2013).
It may also be the case limited cognitive resources and motivational differences are both age-related and influence social judgments in interaction with each other (Stanley & Isaacowitz, 2012). Researchers argue changes in resources with aging (as in the declines we observed in working memory in Chapter 6 ) may lead to an increase in a need for closure with age. This leads to biases in the way older adults process social information.
Research documents a high need for closure does not influence susceptibility to emotional priming influ- ences on neutral stimuli of young and middle-aged adults. However, priming effects increased with higher need for structure in older adults. In other words, older adults with a high need for closure could not inhibit the effects of an emotional prime (e.g., a subliminally presented negative word) on their subsequent behavior (e.g., whether they liked or disliked an abstract figure). Because of age-related changes in personal resources (social and cognitive), motivational factors such as coming to quick and decisive answers to conserve resources become important to the aging adult.
8.5 Personal Control LEARNING OBJECTIVES
What is the multidimensionality of personal control?
How do assimilation and accommodation influence behavior?
What is primary and secondary control? What is the primacy of primary control over
secondary control?
Daniel did not perform as well as he thought he would on his psychology exam. He then had the unhappy task of determining why he did poorly. Was it his fault? Was the exam too picky? To add insult to injury, Daniel needed to raise his grades to maintain his scholarship grant. He decided the exam was too picky. This helped Daniel moti- vate himself to study for his next exams.
How Daniel answered such questions sheds light on how we tend to explain, or attribute our behav- ior, as in the earlier discussion of causal attributions. Among the most important ways we analyze the cause of events is in terms of who or what is in control in a specific situation. Personal control is the degree one believes one’s performance in a situation depends on something that one personally does. A high sense of personal control implies a belief that performance is up to you, whereas a low sense of personal control implies your performance is under the influence of forces other than your own.
Personal control has become an extremely impor- tant idea in a wide variety of settings because of the way it guides behavior and relates to well-being (Brandtstädter, 1997; Lachman, 2006). Personal con- trol is thought to play a role in memory performance (see Chapter 6 ), in intelligence (see Chapter 7 ), in depression (see Chapter 10 ), and in adjustment to and survival in different care settings (see Chapter 5 ).
Multidimensionality of Personal Control The general consensus about personal control is that it is multidimensional (Lachman, Rosnick, & Röcke, 2009). Specifically, one’s sense of control depends on which domain, such as intelligence or health, is being assessed. Lachman and colleagues (2009) found inter- esting changes in control beliefs depending on the
Adult Development in Action If you were designing an advertisement for adults of different ages, how would you approach the sugges- tion to use emotion in the ad?
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236 CHAPTER 8
Control Strategies The research just reviewed primarily examined control- related beliefs such as the belief control is in one’s own hands or in the hands of others. However, a number of theoretical approaches and empirical work examined control-related strategies.
Brandtstädter (1999) first proposed the preser- vation and stabilization of a positive view of the self and personal development in later life involve three interdependent processes. First, people engage in assimilative activities that prevent or alleviate losses in domains that are personally relevant for self-esteem and identity. People may use memory aids more if having a good memory is an important aspect of self- esteem and identity. Second, people make accommo- dations and readjust their goals and aspirations as a way to lessen or neutralize the effects of negative self- evaluations in key domains. If a person notices the time it takes to walk a mile at a brisk pace increased, then the target time can be increased to help lessen the impact of feelings of failure. Third, people use immu- nizing mechanisms that alter the effects of self-discrep- ant evidence. In this case, a person who is confronted with evidence his or her memory performance has declined can look for alternative explanations or sim- ply deny the evidence.
Taking a similar approach, Heckhausen, Wrosch, and Schulz (2010) view control as a motivational sys- tem that regulates human behavior over the life span, in other words, individuals’ abilities to control important outcomes. These researchers define control-related strategies in terms of primary control and secondary control.
domain being examined. They found no changes in a sense of control over one’s health up to the early 70 s. However, when older adults transition from the early 70 s to the mid- 70 s and 80 s, their sense of control over their health declines. This makes sense given the old- est-old experience accumulated losses in their reserved capacity to function. Similarly, positive beliefs about personal control are associated with lower stress across adulthood (Pearlin & Bierman, 2013).
Personal control beliefs are also important in cog- nitive domains. Cavallini and colleagues (2013) showed Sardinians who had a higher sense of personal control over their cognitive changes in later life performed bet- ter on memory tasks than their Milanese counterparts who had a lower sense of personal control.
In summation, researchers found maintaining a sense of control throughout adulthood is linked to bet- ter quality of social relationships, better health, and higher cognitive functioning. They suggest a sense of control may operate as a protective factor for one’s well- being in the face of declining health and other losses associated with the oldest-old.
The same is true in an academic context such as college, where attributions of control are particularly important in determining the causes of success and failure in school. It would be interesting to explore the notion of control in regard to class performance among older and younger students. The exercise in the Discovering Development feature examines this question.
DISCOVERING DEVELOPMENT: HOW MUCH CONTROL DO YOU HAVE OVER YOUR COGNITIVE FUNCTIONING? As you progress through college, you are concerned with your grade-point average, how much you will learn relative to your profession of choice, and your performance on exams. The more control you per- ceive you have over the situation, the more confident you feel. There are two types of control attributions you can make. You can make an “entity” attribution about your performance in school. This means you attribute control to your innate ability to perform. Or you can hold a “skill” perspective. You now attri- bute control over your performance in terms of how
much effort you exert, such as how much you study for an exam.
Are there age differences in these control beliefs? To find out, talk to students at your univer- sity ranging from first-year students to seniors and also ranging in age. There are a lot of older students coming back to school. Find out what they believe is the major cause of the successes and failures in school. Bring your results to class and pool them. See if there are college-level differences and/or age dif- ferences in perceptions of control over academic per- formance. Compare your findings to age differences reported in the text.
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SOCIAL COGNITION 237
Primary control strategies. involve bringing the environment in line with one’s desires and goals. Much like in Brandtstädter’s assimilative activities, action is directed toward changing the external world. So, for example, if you lost your job, and thus your income, primary control strategies would entail an active search for another job (changing the environment so you once again have a steady income).
Secondary control strategies. involve bringing one- self in line with the environment. Much like Brandt- städter’s accommodative activities, it typically involves cognitive activities directed at the self. Secondary control strategies could involve appraising the situ- ation in terms of how you really did not enjoy that particular job.
An important part of this theoretical perspective is that primary control has functional primacy over secondary control. In other words, primary control lets people shape their environment to fit their goals and developmental potential. Thus, primary control has more adaptive value to the individual. The major function of secondary control is to minimize losses or expand levels of primary control.
This relation is depicted in Figure 8.3 . Notice that primary control striving is always high across the life span, but the capacity to achieve primary control
peaks in midlife. As people continue to age, second- ary control striving continues to increase, eventually approaching primary control striving.
Heckhausen and colleagues (2010) believe this has important implications for aging. They find in child- hood much development is directed at expanding the child’s primary control potential, and they predict sta- bility in primary control striving through most of adult life. However, as we enter old age, the maintenance of primary control increasingly depends on secondary control processes. This is because of threats to primary control as a function of biological decline that occurs as we grow older. Thus secondary control increases with age. Research shows secondary control does indeed increase with age (Pfeiffer, 2013).
A particularly important question is how control strategies and beliefs affect emotional well-being. A growing number of studies suggest control beliefs are important contributors to both positive and negative well-being. If someone perceives he or she has control over desirable outcomes, this control is associated with high emotional well-being (Heckhausen et al., 2010; Pfeiffer, 2013). However, how adaptive control beliefs relate to well-being varies with life stage. For young and middle-aged adults, a strong sense of control relates to how we compensate for failure, for example, “We can overcome this momentary failure.” Older adults focus a sense of control on how to master everyday demands (Heckhausen et al., 2010). Finally, for all age groups, planning for the future enhances one’s sense of per- ceived control, and this in turn relates to high life satis- faction (Lachman et al., 2009).
Some Criticisms Regarding Primary Control The notion of increases in accommodative strate- gies (Brandtstädter, 1999) and secondary strategies ( Heckhausen et al., 2010) in older age is not without its criticisms. Carstensen and Freund (1994; Freund & Ritter, 2009) question whether losses people expe- rience, though real, actually threaten the self. In addition, these authors argue age-related changes in goals could also be the result of natural movement through the life cycle, not simply of coping with blocked goals.
Criticisms also can be launched against these approaches to control by considering the globaliza- tion of so many aspects of our functioning. From a
Figure 8.3 Hypothetical life-span trajectories for primary control potential and primary and secondary control striving. Source: Heckhausen, J., Wrosch, C., & Schulz, R. (2010). A motivational theory of life-span development. Psychological Review, 117 (1), 32–60 (p. 36). doi:10.1037/ a0017668 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2820305/figure/F1/. © 2015 Cengage Learning
Primary Control Striving
Secondary Control Striving
Primary Control Capacity
Childhood Midlife Old Age
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238 CHAPTER 8
sociocultural perspective (e.g., cross-cultural research), there is much criticism regarding a bias toward Western cultures in the development of theories such as primary and secondary control, and in particular, the primacy of primary control over secondary control. Stephen J. Gould (1999) suggests in collectivist societies such as those found in Asia, the emphasis is not on individual- istic strategies such as those found in primary control. Instead, the goal is to establish interdependence with others, to be connected to them and bound to a larger social institution. He cites studies showing throughout adulthood, Asian cultures exceed Western cultures in levels of secondary control and emotion-focused cop- ing. Chang (2012) also noted Asian cultures use more secondary control than Latino cultures, but they also show greater social anxiety.
Thus one’s sense of personal control is a complex, multidimensional aspect of personality. Consequently, general normative age-related trends might not be found. Rather, changes in personal control may well depend on one’s experiences in different domains and the culture one grows up in, and may differ widely from one domain to another.
they met at a social gathering for World War II soldiers but couldn’t remember the name of the person who introduced them; she could only describe him as tall and dark-haired. However, this cued Brandon; he remem- bered the man’s name was Tucker. This back-and-forth remembering continued until, to their own amazement, they successfully reconstructed the whole gathering. Their granddaughter was delighted and complimented them on their good memories.
When we typically think about the memories of older adults, we don’t usually think of these kinds of successes. Brandon and Stephanie’s reliance on each other to remember a past event shows how our social cognitive processes serve adaptive functions. In fact, there is a growing interest in how the social context can compensate for memory loss and facilitate mem- ory performance. In this section, we examine two approaches to this issue: collaborative cognition and facilitative social contexts.
Similar to practical intelligence, wisdom, and every- day problem solving discussed in Chapter 7 , the social cognition perspective offers us an enriched understand- ing of social competence in older adulthood. We are interested in how changes in social cognitive function- ing both reflect the changing life contexts of the indi- vidual and affect adaptation to these changing contexts. In the previous sections, we primarily focused on how developmental changes in representations of self or other (such as social beliefs and self-beliefs) influence social cognitive processes such as making attributional judgments. In this section we focus on social cognition as it relates to the dynamic interplay between self, others, and context. A less researched but extremely important domain of social cognition and aging is how the par- ticular types of social settings where we communicate with others, influence our cognitive processing. This relates to a different aspect of social cognition and aging research: the social facilitation of cognitive functioning.
Collaborative Cognition There has been a recent focus in the social cognition and aging literature to examine cognition in social contexts, that is, how cognition works when we are interacting with others. This can be seen in work on the benefits and costs of collaborative cognition on
Adult Development in Action As a professional working with older adults, how would you combine your knowledge of the effects of stereotyping with your knowledge of the importance of personal control beliefs to create an intervention program?
8.6 Social Situations and Social Competence LEARNING OBJECTIVES
What is the social facilitation of cognitive functioning?
What is collaborative cognition, and does it facilitate memory in older adults?
How does the social context influence memory performance in older adults?
Brandon and Stephanie’s granddaughter asked them what happened when they first met. Stephanie recalled
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SOCIAL COGNITION 239
cognitive performance (e.g., memory and problem solving) (Dixon, 2011; Meade, Nokes, & Morrow, 2009). Collaborative cognition occurs when two or more people work together to solve a cognitive task.
Research shows collaborative cognition enhances older adults’ performance on a variety of memory and problem-solving tasks (Dixon, 2011; Meade et al., 2009; Strough & Margrett, 2002), thus serving an important adaptive function for older adults. Following the old saying “Two heads are better than one,” researchers are interested in examining how this type of collaborative context could mitigate deficits in memory we typically see when assessing older adults in the laboratory (see Chapter 6 ).
Research shows older adults can collaborate on story recall as well as problem-solving performance and their performance is better than the average performance of older adults in individual settings (Dixon, 2011). In other words, cognitive performance improves with a collaborative context. On a recall task, by using a cognitive style together that minimizes working memory demands, older married couples performed just as well as younger couples. It is rare to find older adults’ cognitive performance equal to that of younger adults.
Another way to look at the benefits of collabora- tive cognition is to examine how groups accomplish what they want to accomplish. What kinds of processes do older adults use to effectively remember an event as Brandon and Stephanie did? How do older adults divide up the cognitive work when they cooperate on a task?
Older married couples produce more statements resulting from a shared discussion, and provide richer descriptions when working together (Hoppmann & Gerstorf, 2009; Rauers, Riediger, Schmiedek, & Lindenberger, 2011). Unacquainted older adult pairs produced more sociability or support statements. Sociability statements were about agreeing with the partner’s recall or comparing the story with events in their own lives. However, older married couples know each other well and can skip this step and get right down to the business of remembering. Older unacquainted couples are more concerned with being sociable and polite to the other member of the dyad. Older married couples are experienced enough with
one another to bypass the sociability concern and concentrate on better strategies to improve their per- formance. Overall, findings indicate well-acquainted older couples demonstrate an expertise to develop an adaptive pattern of recalling information that includes both social support issues and strategic efforts.
There is also growing evidence of the positive out- comes of collaboration when older adults tackle every- day problem-solving tasks such as errand running and planning a vacation (Allaire, 2012; Kimbler et al., 2012). Interestingly, older adults prefer to collaborate in their problem solving when they perceive deficien- cies in their own functioning but prefer to work alone when they feel competent in the area (Strough et al., 2002). Collaborators of all ages report the benefits include optimizing the decision, enhancing the rela- tionship, and compensating for individual weaknesses (Dixon, 2012; Kimbler et al., 2012). However, col- laboration is not without its costs, such as selfishness,
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240 CHAPTER 8
withholding of one’s honest opinion, and not meeting the other partner’s needs.
Because collaborative cognition is such a common experience and likely to be grounded in the nuances of the relationship people develop over time, it will be a rich area to learn more about the developmental trajectory of memory across adulthood. Most people do remembering in collaborative situations multiple times a day, whether with a spouse/partner or with other family or friends. As we will see in Chapter 11 , the quality of the relationship where this cognitive activity occurs probably has important influences on actual performance. Whether this is true, though, awaits more research.
Social Context of Memory Another approach to identifying conditions when social facilitation of cognition in older adults occurs is in examining contextual variables that influence mem- ory performance. Adams argues memory performance is influenced when the task approximates a real-world learning and social memory experience (Adams et al., 2002). Others have pointed out that prior knowledge (Stein-Morrow & Miller, 2009) and how and how often memories are practiced together (Coman & Hirst, 2012) also influence performance. In this case, what happens to memory performance when the assessment situation approximates the kinds of memory demands that naturally occur in a real-life situation?
A typical and relevant cognitive task for older adults is to transmit sociocultural information to younger gen- erations (Birditt, Tighe, Fingerman, & Zarit, 2012; Qué- niart & Charpentier, 2013). In this context, the older adult would be motivated to communicate effectively.
A storytelling situation is a good example. This kind of context is different from the traditional laboratory con- text, when the demand is to reproduce as much of the con- tent of a text as possible. Adams et al. (2002) found when they placed older adults in a storytelling situation where they were asked to learn and retell a story from memory to a young child, their retellings of the story contained more detail and were more fluent than those of younger adults. Perhaps this superior performance stems from increased motivation in a social context where their concerns were directed at producing an interesting and coherent story for the child. This is a demonstration of how the social- communicative context or experience enhances what is most salient to the individual. Again, this finding illus- trates the importance of taking into consideration the social context of a task situation when examining change in cognitive functioning as we grow older.
Adult Development in Action How might the research on collaborative cognition be used in therapeutic situations you might design if you were working in a long-term care facility?
Social Policy Implications The research on social cognition and aging further accentuates why it is important to consider social factors to explain cognitive functioning in older adult- hood. Factors such as the social context we communi- cate in, the emotions we feel, and the strength of our beliefs and values drive our decisions and social judg- ments in important ways. Thus it is important not to limit explanations of changes in thinking and decision making to cognitive processing variables.
Important social factors influence how and when an individual attends to specific information and when this information influences social cognitive functioning. These factors include those we discussed earlier: motivational goals, cognitive style, attitudes, and values. By not considering these factors, we run
the risk of underestimating the competence of older adults. By considering these factors we can explore the conditions under which older adults flourish and the conditions where we need to focus aid and attention.
This has important policy implications with respect to how we treat older adults in the workforce, estab- lishing health policies, and enhancing the treatment of our older adult population. We can be optimistic about the future promise of research on aging and social cog- nition for identifying and probing such important social components of information processing. To summarize, by looking at cognition in a social context we get a more complete picture of how cognition operates in an everyday social environment.
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SOCIAL COGNITION 241
Summary 8.1 Stereotypes and Aging
How does the content of stereotypes about aging differ across adulthood?
The content of stereotypes varies by age: older adults include more positive stereotypes along with negative ones.
How do younger and older adults perceive the competence of the elderly?
An age-based double standard operates when judging older adults’ failures in memory.
Younger adults rate older adults as more respon- sible despite their memory failures.
How do negative stereotypes about aging unconsciously guide our behavior?
Automatically activated negative stereotypes about aging guide behavior beyond the individu- al’s awareness.
Implicit stereotyping influences the way we patron- ize older adults in our communications.
What are the ways the positive and negative aging stereotypes influence older adults’ behavior?
Stereotypic beliefs have a negative impact on the cognitive performance of older adults.
Stereotypic beliefs influence older adults’ health and physical behavior.
8.2 Social Knowledge Structures and Beliefs
What are social knowledge structures? To understand age differences in social beliefs, we
must first examine content differences. Second, we must assess the strength of the beliefs. Third, we need to know the likelihood beliefs will
affect behavior.
What are social beliefs, and how do they change with age?
Age differences in social beliefs can be attributed to generational differences and life-stage differ- ences.
What are self-perceptions of aging, and what influences them across adulthood?
Labeling theory (the incorporation of negative ste- reotypes) and resilience theory (distancing from negative stereotypes) both operate to create self- perceptions of aging.
8.3 Social Judgment Processes
What is the negativity bias in impression formation, and how does it influence older adults’ thinking?
When forming an initial impression, older adults rely heavily on preexisting social structures.
Older adults weigh negative information more heav- ily in their social judgments than do younger adults.
Older adults use less detailed information in form- ing impressions than do younger adults.
Are there age differences in accessibility of social information?
Social knowledge structures must be available to guide behavior.
Social information must be easily accessible to guide behavior.
Accessibility depends on the strength of the infor- mation stored in memory.
How the situation is framed influences what types of social knowledge will be accessed.
How does processing context influence social judgments? Age-related changes in processing capacity influ-
ence social judgments. Stages of processing suggest we make initial snap
judgments and later correct or adjust them based on more reflective thinking.
To what extent do processing capacity limitations influence social judgments in older adults?
Older adults tend to make more snap judgments because of processing resource limitations.
How do causal attributions and the correspondence bias change with age?
Older adults display a dispositional bias when con- fronted with negative relationship situations.
Older adults display more interactive attributions in negative relationship situations.
The dispositional bias on the part of older adults can be attributed to both processing resource limi- tations and differences in social knowledge that influence their attributional judgments.
Older adults display a higher level of social expertise than younger adults do when forming impressions.
8.4 Motivation and Social Processing Goals
How do goals influence the way we process information, and how does this change with age?
Life-span shifts in goal orientation show interests shift toward physical health and socio-emotional domains increase with age.
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242 CHAPTER 8
What is the primacy of primary control over secondary control?
Primary control has functional primacy over sec- ondary control.
Cross-cultural perspectives challenge the notion of primacy of primary control.
8.6 Social Situations and Social Competence
What is the social facilitation of cognitive functioning? Particular types of social settings where we communi-
cate with others, influence our cognitive processing.
What is collaborative cognition, and does it facilitate memory in older adults?
Collaborating with others in recollection helps facilitate memory in older adults.
Collaborating with others enhances problem solv- ing in older adults.
How does the social context influence memory performance in older adults?
The social context can serve a facilitative function in older adults’ memory performance.
Review Questions 8.1 Stereotypes and Aging
What are stereotypes? How is the content of stereotypes similar across age
groups? How does the content of stereotypes differ across
age groups? What is the age-based double standard of per-
ceived competence in younger and older adults? What do older and younger adults perceive as the
cause of memory failure in older individuals? How does perceived competence influence the way
tasks are assigned to older and younger targets? What other factors besides competence are taken
into consideration when judging older adults’ future performance?
What evidence supports the notion that stereo- types can be automatically activated out of con- scious awareness?
What is implicit stereotyping? Under what conditions are stereotypes activated? How do negative stereotypes of aging influence
young adults’ behavior?
How do emotions influence the way we process information, and how does this change with age?
Older adults tend to focus their processing on posi- tive emotional information more than negative information.
How does a need for closure influence the way we process information, and how does it change with age?
Need for closure is a need for a quick and decisive answer with little tolerance for ambiguity.
Older adults’ social judgment biases are predicted by the degree they need quick and decisive closure. This is not so for younger age groups.
8.5 Personal Control
What is personal control, and what age differences exist in this area?
Personal control is the degree that one believes performance depends on something one does.
Age differences in the degree of personal control depend on the domain being studied. Some evi- dence suggests people develop several strategies concerning personal control to protect a positive self-image.
What is the multidimensionality of personal control?
Older adults perceive less control over specific domains of functioning such as intellectual changes with aging.
Perceived control over health remains stable until it declines in old age.
Older adults perceive less control over social issues and personal appearance.
How do assimilation and accommodation influence behavior?
Assimilative strategies prevent losses important to self-esteem.
Accommodative strategies readjust goals. Immunizing mechanisms alter the effects of self-
discrepant information.
What is primary and secondary control? Primary control helps change the environment to
match one’s goals. Secondary control reappraises the environment in
light of one’s decline in functioning.
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SOCIAL COGNITION 243
8.2 Social Knowledge Structures and Beliefs What three important factors need to be consid-
ered to understand implicit social beliefs? Describe evidence for age differences in the con-
tent of social beliefs. What are labeling theory and resilience theory?
What influences self-perceptions of aging across adulthood?
8.3 Social Judgment Processes What are the stages in attributional processing? What is the negativity bias, and what are the age
differences in its impact? Describe the age differences in the extent that trait
information is used in forming an impression. How does processing capacity affect social cogni-
tive processing? What influences the accessibility of social informa-
tion? What is the status of processing resource limita-
tions as an explanation for social judgment biases? What are causal attributions? What is a correspondence bias? Are there age differences in the correspondence
bias? If so, under what conditions? What accounts for the age differences in the cor-
respondence bias?
8.4 Motivation and Social Processing Goals How do personal goals influence behavior? To what extent are there age differences in emo-
tion as a processing goal in social cognitive func- tioning?
What is need for closure? How does need for closure influence the processing
of social information? Are there age differences in the degree to which
need for closure influences social information pro- cessing?
8.5 Personal Control What evidence is there of age differences in per-
sonal control beliefs? In what domains do older adults exhibit low per-
ceived control, and in what domains do they exhibit higher levels of perceived control?
How are assimilative and accommodative strate- gies adaptive in older adults’ functioning?
Why is primary control viewed as having more functional primacy than secondary control?
What cross-cultural evidence challenges the notion of primary control as functionally more important?
How does personal control influence older adults’ emotional well-being?
8.6 Social Situations and Social Competence What is collaborative cognition? What evidence suggests collaborative cognition
compensates for memory failures in older adults? How does collaborative cognition facilitate
problem-solving behavior? How do marital relationships influence collabora-
tive cognition? How does a storytelling context influence age
differences in memory for stories? What does it mean to say the social context facili-
tates cognitive performance?
INTEGRATING CONCEPTS IN DEVELOPMENT To what degree are declines in processing resource
capacity discussed in Chapter 6 as ubiquitous in their effects on social cognitive processes?
What relations can be found among dispositional traits, personal concerns, and life narratives?
How does emotion as a processing goal relate to socio-emotional selectivity theory in Chapter 10 ?
How does social cognition relate to post-formal thought as discussed in Chapter 7 ?
How does personal control relate to concepts such as memory self-efficacy discussed in Chapter 6 ?
KEY TERMS accommodations Readjustments of goals and aspira- tions as a way to lessen or neutralize the effects of negative self-evaluations in key domains.
age-based double standard When an individual attri- butes an older person’s failure in memory as more seri- ous than a memory failure observed in a young adult.
assimilative activities Exercises that prevent or allevi- ate losses in domains that are personally relevant for self-esteem and identity.
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244 CHAPTER 8
causal attributions Explanations people construct to explain their behavior, that can be situational, dispositional, or interactive.
cognitive style A trait-like pattern of behavior one uses when approaching a problem-solving situation.
collaborative cognition Cognitive performance that results from the interaction of two or more individuals.
correspondence bias Relying more on dispositional information in explaining behavior and ignoring compelling situational information such as extenuating circumstances.
dispositional attribution An explanation for some- one’s behavior that resides within the actor.
immunizing mechanisms Control strategies that alter the effects of self-discrepant evidence.
implicit stereotyping Stereotyped beliefs that affect your judgments of individuals without your being aware of it (i.e., the process is unconscious).
impression formation The way people combine the components of another person’s personality and come up with an integrated perception of the person.
labeling theory Argues that when we confront an age-related stereotype, older adults are more likely to integrate it into their self-perception.
negativity bias Weighing negative information more heavily than positive information in a social judgment.
personal control The belief that what one does has an influence on the outcome of an event.
positivity effect The tendency to attend to and process positive information over negative information.
primary control The act of bringing the environment into line with one’s own desires and goals, similar to Brandtstädter’s assimilative activities.
resilience theory Argues that confronting a negative stereotype results in a rejection of that view in favor of a more positive self-perception.
secondary control The act of bringing oneself in line with the environment, similar to Brandtstädter’s accommodative activities.
self-perception of aging Refers to individuals’ perceptions of their own age and aging.
situational attribution An explanation for someone’s behavior that is external to the actor.
social knowledge A cognitive structure that represents one’s general knowledge about a given social concept or domain.
source judgments Process of accessing knowledge wherein one attempts to determine where one obtained a particular piece of information.
stereotypes Beliefs about characteristics, attributes, and behaviors of members of certain groups.
stereotype threat An evoked fear of being judged in accordance with a negative stereotype about a group to which an individual belongs.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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Personality
9.1 DISPOSITIONAL TRAITS ACROSS ADULTHOOD The Case for Stability: The Five-Factor Model • What Happens to Dispositional Traits Across Adulthood? • Conclusions about Dispositional Traits • Current Controversies: Intraindividual Change and the Stability of Traits
9.2 PERSONAL CONCERNS AND QUALITATIVE STAGES IN ADULTHOOD What’s Different about Personal Concerns? • Jung’s Theory • Erikson’s Stages of Psychosocial Development • Theories Based on Life Transitions • Conclusions about Personal Concerns
9.3 LIFE NARRATIVES, IDENTITY, AND THE SELF Discovering Development: Who Do You Want to Be When You “Grow Up”? • McAdams’s Life-Story Model • Whitbourne’s Identity Theory • Self-Concept and Well-Being • How Do We Know?: Brain Function in Emotion and Depression • Possible Selves • Religiosity and Spiritual Support • Conclusions about Narratives, Identity, and the Self
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 9
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246 CHAPTER 9
Maya Angelou maintains, “There is no agony like bearing an untold story inside of you.” True to her conviction, she has spent a lifetime writing her story in numerous books, poems, and other literary works. She describes an incredible developmental path of oppression, hatred, and hurt that is ultimately transformed into self-awareness, understanding, and compassion. For example, in her later years she realized in confronting the atrocities of the world, if she accepts the fact of evil, she must also accept the fact of good, providing her with as little fear as possible for the anticipation of death. Another example involves integrating spirituality into her self-perception. Author Ken Kelley once asked her how spirituality fits into a way of life. She answered, “There is something more, the spirit, or the soul. I think that that quality encourages our courtesy, and care, and our minds. And mercy, and identity” (Kelley, 1995).
Maya Angelou’s writings reflect some of the key issues involved in personality development we will examine in this chapter. First, we consider whether personality changes or remains stable
across adulthood. We examine this from two perspectives: a trait perspective, as well as personal concerns perspective. Then we discuss how we con- struct life narratives and our identity and self.
One of the oldest debates in psychology con- cerns whether personality development continues across the life span. From the earliest days, promi- nent people argued both sides. William James and Sigmund Freud believed personality was set by the time we reach adulthood. In contrast, Carl Jung asserted personality was continually shaped throughout our lives.
Although we still have these two theoreti- cal camps, one arguing for stability and the other for change, there is a movement in the field to reconcile these differences. Although the data can be viewed as contradictory, results often depend on what specific measures researchers use and the aspect of personality investigated.
Why is the area of personality controversial? The answer lies in how we use personality in daily life. At one level we all believe and base our interactions with people on the presumption their personality remains relatively constant over time. Imagine the chaos that would result if every week or so everyone woke up with a brand new person- ality: The once easygoing husband is now a real tyrant, trusted friends become completely unpre- dictable, and our patterns of social interaction are in shambles. Clearly, to survive in day-to-day life we must rely on consistency of personality.
Still, we also believe people can change, especially with respect to undesirable aspects of their personalities. Picture what it would be like if we could never overcome shyness; if anxiety was a lifelong, incurable curse; or if our idiosyncratic tendencies causing others to tear their hair out could not be eliminated. The assumption of the modifiability of personality is strong indeed. The existence of psychotherapy is a formal verification of that assumption.
So in important ways, our personal theories of personality incorporate both stability and change. Is it any wonder, then, formal psychological theo- ries of personality do the same? Let’s see how those views are described.
Levels of Analysis and Personality Research. Sorting out the various approaches to personality
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PERSONALITY 247
“raw stuff” of personality, whereas each successive level must be constructed to a greater extent. In the following sections, we use McAdams’s levels to orga- nize our discussion of adulthood personality. Let’s begin with the “raw stuff” and see how dispositional traits are structured in adulthood.
helps us understand what aspects of personality the various researchers describe. Drawing on the work of several theorists and researchers, McAdams (1999) describes three parallel levels of personality structure and function, each containing a wide range of personality constructs: dispositional traits, personal concerns, and life narrative.
Dispositional traits consist of aspects of per- sonality consistent across different contexts and can be compared across a group along a contin- uum representing high and low degrees of the characteristic. Dispositional traits are the level of personality most people think of first, and they include commonly used descriptors such as shy, talkative, authoritarian, and the like.
Personal concerns consist of things impor- tant to people, their goals, and their major concerns in life. Personal concerns are usually described in motivational, developmental, or strategic terms; they reflect the stage of life a person is in at the time.
Life narrative consists of the aspects of person- ality pulling everything together, those inte- grative aspects that give a person an identity or sense of self. The creation of one’s identity is the goal of this level.
In an extension of McAdams’s model of personality, Karen Hooker (Bolkan & Hooker, 2012; Hooker & McAdams, 2003) added three processes that act in tandem with the three structural components of personality proposed by McAdams. State processes act with dispositional traits to create transient, short-term changes in emotion, mood, hunger, anxiety, and so on. Personal concerns act in tandem with self-regulatory processes that include such processes as primary and secondary control (discussed in Chapter 8 ). Finally, cognitive processes act jointly with life narratives to create natural interaction that occur between a storyteller and listener, processes central in organizing life stories.
Finally, as one moves from examining disposi- tional traits to personal concerns to life narrative (and their corresponding processes), it becomes more likely observable change will take place (Graham & Lachman, 2012; Newton & Stewart, 2012). In a sense, the level of dispositional traits can be viewed as the
9.1 Dispositional Traits across Adulthood LEARNING OBJECTIVES
What is the five-factor model of dispositional traits?
What happens to dispositional traits across adulthood?
What can we conclude from theory and research on dispositional traits?
A bby was attending her high school reunion. She hadn’t seen her friend Michelle in 20 years. Abby remembered that in high school Michelle was always surrounded by a group of people. She always walked up to people and initiated conversations, was at ease with strangers, pleas- ant, and often described as the “life of the party.” Abby wondered if Michelle would be the same outgoing person she was in high school.
Many of us eventually attend a high school reunion. It is amusing, so it is said, to see how our classmates changed over the years. In addition to noticing gray or missing hair and a few wrinkles, we should pay attention to personality characteristics. The questions that sur- faced for Abby are similar to the ones we generate our- selves. For example, will Katy be the same outgoing per- son she was as captain of the cheerleaders? Will Ted still be as concerned about social issues at 48 as he was at 18 ?
To learn as much about our friends as possible we could make careful observations of our classmates’ personalities over the course of several reunions. Then, at the gathering marking 60 years since graduation, we could examine the trends we observed. Did our classmates’ personalities change substantially or did they remain essentially the same as they were 60 years earlier?
How we think these questions will be answered provides clues to our personal biases concerning per- sonality stability or change across adulthood. As we will see, biases about continuity and discontinuity are
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248 CHAPTER 9
The Case for Stability: The Five-Factor Model
Although many trait theories of personality have been proposed over the years, few have been concerned with or have been based on adults of different ages. A major exception to this is the five-factor model proposed by Costa and McCrae (1994; Costa & McCrae, 2011). Their model is strongly grounded in cross-sectional, longitudinal, and sequential research. The five-factor model consists of five independent dimensions of per- sonality: neuroticism, extraversion, openness to experi- ence, agreeableness, and conscientiousness.
The first three dimensions of Costa and McCrae’s model—neuroticism, extraversion, and openness to experience—have been the ones most heavily researched. Each of these dimensions is represented by six facets reflecting the main characteristics associated with it. The remaining two dimensions were added to the original three in the late 1980s to account for more data and to bring the theory closer to other trait theories. Let’s con- sider each of the five dimensions briefly.
Neuroticism. The six facets of neuroticism are anxiety, hostility, self-consciousness, depression, impulsiveness, and vulnerability. Anxiety and hos- tility form underlying traits for two fundamental emotions: fear and anger. Although we all experi- ence these emotions at times, the frequency and intensity with which they are felt vary from one person to another. People who are high in trait anxiety are nervous, high-strung, tense, worried, and pessimistic. Besides being prone to anger, hos- tile people are irritable and tend to be hard to get along with.
The traits of self-consciousness and depres- sion relate to the emotions shame and sorrow. Being high in self-consciousness is associated with being sensitive to criticism, teasing, and feelings of inferiority. Trait depression involves feelings of sadness, hopelessness, loneliness, guilt, and low self-worth.
The final two facets of neuroticism—impul- siveness and vulnerability—are most often mani- fested as behaviors rather than as emotions. Impulsiveness is the tendency to give in to temp- tation and desires because of a lack of willpower
more obvious in personality research than in any other area of adult development.
In addition to considering the old debate of whether Michelle’s personality characteristics remained stable or have changed, Abby’s description of Michelle sug- gests Michelle is an outgoing, or extroverted, person. How did Abby arrive at this judgment? She prob- ably combined several aspects of Michelle’s behav- ior into a concept that describes her rather concisely. What we have done is use the notion of a personality trait. Extending this same reasoning to many areas of behavior is the basis for trait theories of personality. More formally, people’s characteristic behaviors can be understood through attributes that reflect underlying dispositional traits that are relatively enduring aspects of personality. We use the basic tenets of trait theory when we describe ourselves and others with such terms as calm, aggressive, independent, friendly, and so on.
Three assumptions are made about traits (Costa & McCrae, 2011). First, traits are based on comparisons of individuals, because there are no absolute quantita- tive standards for concepts such as friendliness. Sec- ond, the qualities or behaviors making up a particular trait must be distinctive enough to avoid confusion. Imagine the chaos if friendliness and aggressiveness had many behaviors in common and others were vastly different! Finally, the traits attributed to a spe- cific person are assumed to be stable characteristics. We normally assume people who are friendly in sev- eral situations are going to be friendly the next time we see them.
These three assumptions are all captured in the classic definition of a trait: “ A trait is any distinguish- able, relatively enduring way that one individual differs from others ” (Guilford, 1959, p. 6). Based on this defini- tion, trait theories assume little change in personality occurs across adulthood.
Most trait theories have several common guiding principles. An important one for this discussion con- cerns the structure of traits. Like it does for intelligence (see Chapter 7 ), structure concerns the way traits are organized within the individual. This organization is usually inferred from the pattern of related and unrelated personality characteristics, and is generally expressed in terms of dimensions. Personality struc- tures can be examined over time to see whether they change with age.
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PERSONALITY 249
business administration, and sales. They value humanitarian goals and a person-oriented use of power. People low in extraversion tend to pre- fer task-oriented jobs, such as architecture or accounting.
Openness to Experience. The six facets of open- ness to experience represent six different areas. In the area of fantasy, openness means having a vivid imagination and active dream life. In aesthetics, openness is seen in the appreciation of art and beauty, sensitivity to pure experience for its own sake. When open to action, people exhibit a will- ingness to try something new such as a new kind of cuisine, movie, or a travel destination. People who are open to ideas and values are curious and value knowledge for the sake of knowing. Open people also tend to be open-minded in their values, often admitting what may be right for one person may not be right for everyone. This outlook is a direct outgrowth of individuals’ willingness to think of different possibilities in addition to their tendency to empathize with others in different circum- stances. Open people also experience their own feelings strongly and see them as a major source of meaning in life.
Not surprisingly, openness to experience is also related to occupational choice. Open people are likely to be found in occupations that place a high value on thinking theoretically or philosoph- ically and less emphasis on economic values. They are typically intelligent and tend to subject them- selves to stressful situations. Occupations such as psychologist or minister, for example, appeal to open people.
Agreeableness. The easiest way to understand the agreeableness dimension is to consider the traits characterizing antagonism. Antagonistic people tend to set themselves against others; they are skeptical, mistrustful, callous, unsympathetic, stubborn, and rude; and they have a defective sense of attachment. Antagonism may be manifested in ways other than overt hostility. Some antagonistic people are skillful manipulators or aggressive go- getters with little patience.
Scoring high on agreeableness, the opposite of antagonism, may not always be adaptive either,
and self-control. Consequently, impulsive people often do things in excess, such as overeating and overspending, and they are more likely to smoke, gamble, and use drugs. Vulnerability involves a lowered capability to deal effectively with stress. Vulnerable people tend to panic in a crisis or emer- gency and highly dependent on others for help.
Costa and McCrae (1998, 2011) note, in gen- eral, people high in neuroticism tend to be high in each of the traits involved. High neuroticism typically results in violent and negative emotions that interfere with people’s ability to handle prob- lems or to get along with other people. We can see how this cluster of traits operates. A person gets anxious and embarrassed in a social situation such as a class reunion; the frustration in dealing with others makes the person hostile, leading to exces- sive drinking at the party, and may result in sub- sequent depression for making a fool of oneself, and so on.
Extraversion. The six facets of extraversion can be grouped into three interpersonal traits (warmth, gregariousness, and assertiveness) and three tem- peramental traits (activity, excitement seeking, and positive emotions). Warmth, or attachment, is a friendly, compassionate, intimately involved style of interacting with other people. Warmth and gregariousness (a desire to be with other people) make up what is sometimes called sociability. Gre- garious people thrive on crowds; the more social interaction the better. Assertive people make natu- ral leaders, take charge easily, make up their own minds, and readily express their thoughts and feelings.
Temperamentally, extraverts like to keep busy; they are the people who seem to have endless energy, talk fast, and want to be on the go. They prefer to be in stimulating, exciting environments and often go searching for a challenging situation. This active, exciting lifestyle is evident in the extra- vert’s positive emotion; these people are walking examples of zest, delight, and fun.
An interesting aspect of extraversion is that this dimension relates well to occupational inter- ests and values. People high in extraversion tend to have people-oriented jobs, such as social work,
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250 CHAPTER 9
there were no significant changes across overall per- sonality patterns. However, some interesting changes did occur in the very old. There was an increase in sus- piciousness and sensitivity and could be explained by increased wariness of victimization in older adulthood.
Stability was also observed in past longitudinal data conducted over a 7 - year period (Mõttus, Johnson, & Deary, 2012; Roberts & DelVecchio, 2000), to as long as a 30 - year span (Leon, Gillum, Gillum, & Gouze, 1979). According to this evidence, it appears individu- als change little in self-reported personality traits over periods of up to 30 years long and over the age range of 20 to 90 years of age.
However, there is growing evidence both stability and change can be detected in personality trait develop- ment across the adult life span (Allemand, Zimprich, & Hendriks, 2008; Caspi, Roberts, & Shiner, 2005; Mathias, Allemand, Zimprich, & Martin, 2008; Mõttus, Johnson, & Deary, 2012). These findings came about because of advances in statistical techniques. Researchers find the way people differ in their personality becomes more pro- nounced with older age (Allemand et al., 2008; Mõttus, Johnson, & Deary, 2012). For example, studies (e.g., Donnellan & Lucas, 2008) find extraversion and open- ness decrease with age whereas agreeableness increases with age. Conscientious appears to peak in middle age. Most interestingly, neuroticism often disappears or is much less apparent in late life. Such changes are found in studies that examine larger populations across a larger age range (e.g., 16 to mid- 80 s) and greater geographical regions (e.g., United States and Great Britain).
Despite the impressive collection of research findings for personality stability using the five- factor model, there is growing evidence for personality change. Ursula Staudinger and colleagues have a per- spective that reconciles these differences (Mühlig- Versen, Bowen, & Staudinger, 2012; Staudinger & Kunzman, 2005; Staudinger & Kessler, 2008). They suggest personality takes on two forms: adjustment and growth. Personality adjustment involves devel- opmental changes in terms of their adaptive value and functionality, such as functioning effectively within soci- ety, and how personality contributes to everyday life run- ning smoothly. Personality growth refers to ideal end states such as increased self-transcendence, wisdom, and integrity. Examples of this will be discussed later and includes Erikson’s theory.
however. These people may tend to be overly dependent and self-effacing, traits that often prove annoying to others.
Conscientiousness. Scoring high on conscien- tiousness indicates one is hardworking, ambitious, energetic, scrupulous, and persevering. Such people have a strong desire to make something of themselves. People at the opposite end of this scale tend to be negligent, lazy, disorganized, late, aim- less, and not persistent.
What Happens to Dispositional Traits Across Adulthood?
Costa and McCrae investigated whether the traits that make up their model remain stable across adulthood (e.g., Costa & McCrae, 1988, 1994, 1997, 2011). They suggest personality traits stop changing by age 30 ; then appear to be “set in plaster” (Costa & McCrae, 1994, p. 21 ). The data from the Costa, McCrae, and colleagues’ studies came from the Baltimore Longitudinal Study of Aging for the 114 men who took the Guilford-Zimmerman Temperament Survey (GZTS) on three occasions, with each of the two follow-up tests about six years apart.
What Costa and colleagues found was surpris- ing. Even over a 12 - year period, the 10 traits measured by the GZTS remained highly stable; the correlations ranged from . 68 to . 85 . In much of personality research we might expect to find this degree of stability over a week or two, but to see it over 12 years is noteworthy.
We would normally be skeptical of such consistency over a long period. But similar findings were obtained in other studies. In a longitudinal study of 60 - , 80 - , and 100 - year-olds, Martin and colleagues (2003) found
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PERSONALITY 251
To summarize, there appears to be increases in adjustment aspects of personality with increasing age, and it could be normative. At the same time, however, the basic indicators of personality growth tend to show stability or decline. You might ask, what’s going on?
The most likely answer is personality growth or change across adulthood does not normally occur unless there are special circumstances and with an environ- mental push for it to occur. Thus, the personality-related adjustment grows in adulthood does so in response to ever-changing developmental challenges and tasks, such as establishing a career, marriage, and family.
Conclusions about Dispositional Traits What can we conclude about the development of dis- positional traits across adulthood? Clearly, the over- whelming evidence supports the view personality traits remain stable throughout adulthood when data are averaged across many different kinds of people. However, if we ask about specific aspects of personality in specific kinds of people, we are more likely to find evidence of both change and stability.
A reasonable resolution to the trait debate is to understand the answer to the basic question depends on how the data are analyzed (Hill, Turiano, Mroczek, & Roberts, 2012; Mõttus et al., 2012; Mroczek & Spiro, 2003). Mroczek and colleagues challenge the conclu- sions drawn from the typical longitudinal studies on stability and change in personality by examining per- sonality across the adult life span at the level of the individual. We describe this challenge in more detail in the Current Controversies feature.
Both of these personality dimensions interact because growth cannot occur without adjustment. However, Staudinger argues while growth in terms of ideal end states does not necessarily occur in every- one, since it is less easily acquired, strategies for adjust- ment develops across the latter half of the life span. This framework can be used to interpret stability and change in the Big Five personality factors.
First, the most current consensus of change in the Big Five with increasing age is the absence of neuroticism and the presence of agreeableness and conscientiousness. These three traits are associated with personality adjustment, especially in terms of becoming emotionally less volatile and more attuned to social demands and social roles (Mühlig-Versen et al., 2012; Staudinger & Kunzmann, 2005). These charac- teristics allow older adults to maintain and regain levels of well-being in the face of loss, threats, and challenges; common occurrences in late life.
Studies also show a decrease in openness to new experiences with increasing age (e.g., Graham & Lach- man, 2012; Helson & Kwan, 2000; Roberts et al., 2006; Srivastava et al., 2003). Staudinger argues openness to experience is related to personal maturity because it is highly correlated with ego development, wisdom, and emotional complexity. Evidence suggests these three aspects of personality (ego level, wisdom, and emotional complexity) do not increase with age and may show decline (Staudinger, Dörner, & Mickler, 2005; Grühn, Lumley, Diehl, & Labouvie-Vief, 2013; Mühlig-Versen et al., 2012). Staudinger concludes personal growth in adulthood appears to be rare rather than normative.
CURRENT CONTROVERSIES: INTRAINDIVIDUAL CHANGE AND THE STABILITY OF TRAITS The controversy continues today as to if personality remains stable across the life span or changes. Given personality traits have shown to be important predic- tors of mental and physical health as well as psycho- logical well-being, potential changes in personality can have important implications for gains and declines in life outcomes. However, as this chapter indicates, there is no clear evidence for one position or the other.
An important aspect to consider in this controversy is the level of analysis stability and change is determined.
Typically, stability and change are examined through average (mean) level comparisons over time. In other words, does an age group’s mean level on a particular personality trait such as extraversion remain stable from one point in time to another (say 10 years apart) or does it change?
Several researchers (e.g., Hill et al., 2012; Mõttus et al., 2012; Mroczek & Spiro, 2003) suggest examining change in mean levels of a personality trait does not adequately address stability and change at the level of the individual. A group mean hides the extent indi- vidual people change. In an alternative approach, they also examine the extent each person in their longitu- dinal studies changes or remains the same over time. This allows them to ask the questions, “Do some people
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252 CHAPTER 9
sedan for a red sports car, and began working out regu- larly at the health club after years of being a couch potato. Andy claims he hasn’t felt this good in years; he is happy to be making this change in middle age. All of Andy’s friends agree: This is a clear case of midlife crisis— or is it?
Many people believe strongly middle age brings with it a normative crisis called the midlife crisis. There would appear to be lots of evidence to sup- port this view, based on case studies like Andy’s. But is everything as it seems? We’ll find out in this sec- tion. First we consider the evidence people’s priorities and personal concerns change throughout adulthood, requiring adults to reassess themselves from time to time. This alternative position to the five-factor model discussed earlier claims change is the rule during adulthood.
What does it mean to know another person well? McAdams and Olson (2010) believe to know another person well takes more than just knowing where he or she falls on the dimensions of dispositional traits. Rather, it means knowing what issues are important to a person, that is, what the person wants, how the individual goes about getting what he or she wants, what the person’s plans are for the future, how the person interacts with others who provide key per- sonal relationships, and so forth. In short, we need to know something about a person’s personal concerns. Personal concerns reflect what people want during particular times of their lives and within specific domains; they are the strategies, plans, and defenses people use to get what they want and avoid getting what they don’t.
What’s Different about Personal Concerns? Many researchers began analyzing personality in ways explicitly contextual, in contrast to work on
Another important issue for future research is the role of life experiences. If a person experiences few events inducing him or her to change, then change is unlikely. In this view a person will be at 60 much the same as he or she is at 30 , all other factors being held constant. As we show later, this idea has been incorpo- rated formally into other theories of personality.
What about that high school reunion? On the basis of dispositional traits, then, we should have little difficulty knowing our high school classmates many years from now.
remain stable whereas others change?” and, if there are people who change, “Do some people change more than others?” Data addressing these questions indicate important individual differences in the extent people do or do not change.
This approach allows a more detailed answer to questions of stability and change. When we rely on group level analyses in major longitudinal approaches such as McCrae and Costa’s (1994), we see there is
primarily stability. However, when we examine individ- uals’ respective growth curves, we see a more complex picture of personality development. Whereas a large proportion of individuals may remain stable, there is a substantial group of individuals whose personality traits either increase or decrease over time. Perhaps we can see a resolution to this debate in the future as more intraindividual studies on personality development emerge.
Adult Development in Action If you were a counselor, how would you use research on stability and dispositional traits to understand why it is difficult for people to change their behavior?
9.2 Personal Concerns and Qualitative Stages in Adulthood LEARNING OBJECTIVES
What are personal concerns? What are the main elements of Jung’s theory? What are the stages in Erikson’s theory? What
types of clarifications and extensions of it have been offered? What research evidence is there to support his stages?
What are the main points and problems with theories based on life transitions?
What can we conclude about personal concerns?
A ndy showed all the signs. He divorced his wife of nearly 20 years to enter into a relationship with a woman 15 years younger, sold his ordinary-looking mid-size
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PERSONALITY 253
Jung’s Theory Jung represents a turning point in the history of psy- choanalytic thought. Initially allied with Freud, he soon severed the tie and developed his own ideas that have elements of both Freudian theory and humanistic psychology. He was one of the first theorists to believe in personality development in adulthood; this marked a major break with Freudian thought, that argued per- sonality development ended in adolescence.
Jung’s theory emphasizes each aspect of a person’s personality must be in balance with all the others. This means each part of the personality will be expressed in some way, whether through normal means, neurotic symptoms, or in dreams. Jung asserts the parts of the personality are organized in such a way as to produce two basic orientations of the ego. One of these orienta- tions is concerned with the external world; Jung labels it extraversion. The opposite orientation, toward the inner world of subjective experiences, is labeled intro- version. To be psychologically healthy, both of these orientations must be present, and they must be bal- anced. Individuals must deal with the external world effectively and also be able to evaluate their inner feel- ings and values. When people emphasize one orienta- tion over another, they are classified as extraverts or introverts.
Jung advocates two important age-related trends in personality development. The first relates to the introversion–extraversion distinction. Young adults are more extraverted than older adults, perhaps because of younger people’s needs to find a mate, have a career, and so forth. With increasing age, however, the need for balance creates a need to focus inward and explore personal feelings about aging and mortal- ity. Thus, Jung argued with age comes an increase in introversion.
The second age-related trend in Jung’s theory involves the feminine and masculine aspects of our personalities. Each of us, according to Jung, has ele- ments of both masculinity and femininity. In young adulthood, however, most of us express only one of them while working hard to suppress the other. In other words, young adults most often act in accordance with gender-role stereotypes appropriate to their culture. As they grow older, people begin to let out the suppressed parts of their personality. This means men begin to
dispositional traits that ignores context. This work emphasizes the importance of sociocultural influences on development that shape people’s wants and behav- iors (Hooker & McAdams, 2003). Röcke and Lach- man (2008) showed a person-centered approach that focuses on personal control and social relationship qualityis better than dispositional traits in understand- ing life satisfaction.
Although relatively little research has been con- ducted on the personal concerns level of personality, a few things are clear (Hooker & McAdams, 2003; McAdams & Olson, 2010). Personality constructs at this level are not reducible to traits. Rather, such con- structs need to be viewed as conscious descriptions of what a person is trying to accomplish during a given period of life and what goals and goal-based concerns the person has.
As Cantor (1990) initially noted and others (e.g., Norem, 2012) summarized, these constructs speak directly to the question of what people actually do and the goals they set for themselves in life. Moreover, we expect considerable change would be seen at this level of personality, given the importance of sociocultural influences and the changing nature of life-tasks as people mature. Accompanying these goals and moti- vations that define personal concerns are the self- regulation processes implemented to effect change in personal concerns. The transition from primary control to secondary control or from assimilative to accommodative coping discussed in Chapter 8 enables people to recalibrate their goals and personal con- cerns in later life. This process serves the important function of maintaining satisfaction and meaningful- ness in life (Hooker & McAdams, 2003; McAdams & Olson, 2010).
In contrast to the limited empirical data on the development of personal concerns, the theoreti- cal base is arguably the richest. For the better part of a century, the notion that people’s personality changes throughout the life span has been described in numerous ways, typically in theories postulating qualitative stages that reflect the central concern of that period of life. In this section, we consider several of these theories and evaluate the available evidence for each. Let’s begin with Carl Jung’s theory—the theory that started people thinking about personality change in midlife.
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254 CHAPTER 9
Erikson’s Stages of Psychosocial Development
The best-known life-span theorist is Erik Erikson (1982), who called attention to cultural mechanisms involved in personality development. According to him, personality is determined by the interaction between an inner maturational plan and external societal demands. He proposes the life cycle has eight stages of development, summarized in Table 9.1 . Erik- son believed the sequence of stages is biologically fixed.
Each stage in Erikson’s theory is marked by a struggle between two opposing tendencies and both are experienced by the person. The names of the stages reflect the issues that form the struggles. The struggles are resolved through an interactive process involving both the inner psychological and the outer social influ- ences. Successful resolutions establish the basic areas of psychosocial strength; unsuccessful resolutions impair ego development in a particular area and adversely affect the resolution of future struggles. Thus each stage in Erikson’s theory represents a kind of crisis.
The sequence of stages in Erikson’s theory is based on the epigenetic principle , meaning each psychoso- cial strength has its own special time of ascendancy, or period of particular importance. The eight stages rep- resent the order of this ascendancy. Because the stages extend across the whole life span, it takes a lifetime to
behave in ways that earlier in life they would have considered feminine, and women behave in ways that they formerly would have thought masculine. These changes achieve a better balance that allows men and women to deal more effectively with their individual needs rather than being driven by socially defined stereotypes. This balance, however, does not mean a reversal of sex roles. On the contrary, it represents the expression of aspects of ourselves that have been there all along but we have simply not allowed showing. We return to this issue at the end of the chapter when we consider gender-role development.
Jung’s ideas that self and personality are organized by symbols and stories and the notion we transcend the dualities of femininity–masculinity and conscious– unconscious, among others, have now become active areas of research (Grühn et al., 2013; Labouvie-Vief, 2008; Labouvie-Vief, Grühn, & Mouras, 2009). How- ever, as Labouvie-Vief and colleagues point out, most empirical evidence suggests these reorganizations proposed by Jung are more indicative of advanced or exceptional development.
Jung stretched traditional psychoanalytic theory to new limits by postulating continued development across adulthood. Other theorists took Jung’s lead and argued not only personality development occurred in adult- hood but also it did so in an orderly, sequential fashion. We consider the sequences developed by Erik Erikson.
Source: From The Life Cycle Completed: A Review by Erik H. Erikson. Copyright © 1982 by Rikan Enterprises, Ltd. Used by permission of W. W. Norton & Company, Inc.
Table 9.1
Summary of Erikson's Theory of Psychosocial Development, with Important Relationships and Psychosocial Strengths Acquired at Each Stage Stage Psychosocial Crisis Significant Relations Basic Strengths
1. Infancy Basic trust versus basic mistrust Maternal person Hope
2. Early childhood Autonomy versus shame and doubt Paternal people Will
3. Play age Initiative versus guilt Basic family Purpose
4. School age Industry versus inferiority “Neighborhood,” school Competence
5. Adolescence Identity versus identity confusion Peer groups and outgroups; models of leadership
Love
6. Young adulthood Intimacy versus isolation Partners in friendship, sex competition, cooperation
Love
7. Adulthood Generativity versus stagnation Divided labor and shared household Care
8. Old age Integrity versus despair Humankind, “my kind” Wisdom
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PERSONALITY 255
identity. If intimacy is not achieved, isolation results. One way to assist the development of intimacy is to choose a mate who represents the ideal of all one’s past experiences. The psychosocial strength that emerges from the intimacy–isolation struggle is love.
With the advent of middle age the focus shifts from intimacy to concern for the next generation, expressed as generativity versus stagnation. The struggle occurs between a sense of generativity (the feeling people must maintain and perpetuate society) and a sense of stagnation (the feeling of self-absorption). Generativ- ity is seen in such things as parenthood; teaching, like the man in the photograph; or providing goods and services for the benefit of society. If the challenge of generativity is accepted, the development of trust in the next generation is facilitated, and the psychosocial strength of care is obtained. We examine generativity in more detail a bit later in this chapter.
In old age, individuals must resolve the strug- gle between ego integrity and despair. This last stage begins with a growing awareness of the nearness of the end of life, but it is actually completed by only a small number of people (Erikson, 1982). According to Erikson (1982), this struggle comes about as older adults try to understand their lives in terms of the future of their family and community. Thoughts of a person’s own death are balanced by the realization they live on through children, grandchildren, great-grand- children, and the community as a whole. This real- ization produces what Erikson calls a “life-affirming involvement” in the present.
To achieve integrity, a person must come to terms with the choices and events that made his or her life
acquire all of the psychosocial strengths. Moreover, Erikson realizes present and future behavior must have its roots in the past, because later stages build on the foundation laid in previous ones.
Erikson argues the basic aspect of a healthy per- sonality is a sense of trust toward oneself and others. Thus the first stage in his theory involves trust versus mistrust, representing the conflict an infant faces in developing trust in a world it knows little about. With trust come feelings of security and comfort.
The second stage, autonomy versus shame and doubt, reflects children’s budding understanding they are in charge of their own actions. This understanding changes them from totally reactive beings to ones who can act on the world intentionally. Their autonomy is threatened, however, by their inclinations to avoid responsibility for their actions and to go back to the security of the first stage.
In the third stage, the conflict is initiative versus guilt. Once children realize they can act on the world and are somebody, they begin to discover who they are. They take advantage of wider experience to explore the environment on their own, ask many questions about the world, and imagine possibilities about themselves.
The fourth stage is marked by children’s increas- ing interests in interacting with peers, their need for acceptance, and their need to develop competencies. Erikson views these needs as representing industry versus inferiority, and is manifested behaviorally in children’s desire to accomplish tasks by working hard. Failure to succeed in developing self-perceived compe- tencies results in feelings of inferiority.
During adolescence, Erikson believes we deal with the issue of identity versus identity confusion. The choice we make—the identity we form—is not so much who we are but who we can become. The strug- gle in adolescence is choosing from among a multitude of possible selves the one we will become. Identity con- fusion results when we are torn over the possibilities. The struggle involves trying to balance our need to choose a possible self and the desire to try out many possible selves.
During young adulthood the major developmen- tal task, achieving intimacy versus isolation, involves establishing a fully intimate relationship with another. Erikson (1968) argues intimacy means the sharing of all aspects of oneself without fearing the loss of © M
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versus stagnation. Finally, Logan points out the issue of understanding ourselves as worthwhile and whole is first encountered during adolescence (identity vs. identity confusion) and is re-experienced during old age (integrity vs. despair). Logan’s analysis emphasizes psychosocial development, although complicated on the surface, may actually reflect only a small number of issues. Moreover, he points out we do not come to a single resolution of these issues of trust, achievement, and wholeness. Rather, they are issues we struggle with our entire lives.
Slater (2003) expanded on Logan’s reasoning, suggesting the central crisis of generativity versus stagnation includes struggles between pride and embarrassment, responsibility and ambivalence, career productivity and inadequacy, as well as parenthood and self-absorption. Each of these conflicts provides further knowledge about generativity as the intersec- tion of society and the human life cycle.
Researchers focusing on emerging adulthood raised the possibility of an additional stage specific to this phase of life. Patterson (2012) speculates a fifth stage she labels incarnation versus impudence is needed between adolescence (identity vs. role confu- sion) and young adulthood (intimacy vs. isolation). For Patterson, this crisis is “resolved through experimental sexuality, temporal and spatial social and intimate rela- tionships, interdependence and self-sufficiency and dependence and helplessness, and relativist and abso- lutist ideological experimentation.”
Some critics argue Erikson’s stage of generativity is much too broad to capture the essence of adulthood. Kotre (1999, 2005) contends adults experience many opportunities to express generativity that are not equivalent and do not lead to a general state. Rather, he sees generativity more as a set of impulses felt at dif- ferent times and in different settings, such as at work or in grandparenting. More formally, Kotre describes five types of generativity: biological and parental gen- erativity, that concerns raising children; technical gen- erativity, relating to the passing of specific skills from one generation to another; cultural generativity, refer- ring to being a mentor (discussed in more detail in Chapter 12 ); agentic generativity, the desire to be or to do something that transcends death; and communal generativity, manifesting as a person’s participation in a mutual, interpersonal reality. Only rarely, Kotre
unique. There must also be an acceptance of the fact one’s life is drawing to a close. Research shows a con- nection between engaging in a life review and achiev- ing integrity, so life review forms the basis for effective mental health interventions (Westerhof, Bohlmeijer, & Webster, 2010).
Who reaches integrity? Erikson (1982) emphasizes people who demonstrate integrity made many differ- ent choices and follow different lifestyles; the point is everyone has this opportunity to achieve integrity if they strive for it. Those who reach integrity become self-affirming and self-accepting; they judge their lives to have been worthwhile and good. They are glad to have lived the lives they did.
Clarifications and Expansions of Erikson’s Theory. Erikson’s theory made a major impact on thinking about life-span development. However, some aspects of his theory are unclear, poorly defined, or unspeci- fied. Traditionally, these problems led critics to dismiss the theory as untestable and incomplete. However, the situation is changing. Other theorists tried to address these problems by identifying common themes, speci- fying underlying mental processes, and reinterpret- ing and integrating the theory with other ideas. These ideas are leading researchers to reassess the usefulness of Erikson’s theory as a guide for research on adult per- sonality development.
Logan (1986) points out Erikson’s theory can be considered as a cycle that repeats: from basic trust to identity and from identity to integrity. In this approach the developmental progression is trust → achieve- ment → wholeness. Throughout life we first establish we can trust other people and ourselves. Initially, trust involves learning about ourselves and others, repre- sented by the first two stages (trust vs. mistrust and autonomy vs. shame and doubt). The recapitulation of this idea in the second cycle is seen in our struggle to find a person with whom we can form a close relation- ship yet not lose our own sense of self (intimacy vs. isolation).
In addition, Logan shows how achievement— our need to accomplish and to be recognized for it—is a theme throughout Erikson’s theory. During childhood this idea is reflected in the two stages ini- tiative versus guilt and industry versus inferiority, whereas in adulthood it is represented by generativity
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The components of McAdams’s model relate dif- ferently to personality traits. Generative concern is a general personality tendency of interest in caring for younger individuals, and generative action is the actual behaviors that promote the well-being of the next generation. Generative concern relates to life satisfac- tion and overall happiness, whereas generative action does not. For example, new grandparents may derive satisfaction from their grandchildren and are greatly concerned with their well-being but have little desire to engage in the daily hassles of caring for them on a regular basis.
Although they can be expressed by adults of all ages, certain types of generativity are more common at some ages than others. Middle-aged and older adults show a greater preoccupation with generativity themes than do younger adults in their accounts of person- ally meaningful life experiences (McAdams & Olson, 2010). Middle-aged adults make more generative com- mitments (e.g., “save enough money for my daughter to go to medical school”), reflecting a major difference in the inner and outer worlds of middle-aged and older adults as opposed to younger adults.
Similar research focusing specifically on middle- aged women yields comparable results. Hills (2013) argues leaving a legacy, a major example of generativity in practice, is a core concern in midlife, more so than at
contends, is there a continuous state of generativity in adulthood. He asserts the struggles identified by Erik- son are not fought constantly; rather, they probably come and go. We examine this idea in more detail in the next section.
Research on Generativity. Perhaps the central period in adulthood from an Eriksonian perspective is the stage of generativity versus stagnation. One of the best empirically based efforts to describe generativity is McAdams’s model (McAdams, 2001; McAdams & Olson, 2010; Wilt, Cox, & McAdams, 2010) shown in Figure 9.1 .
This multidimensional model shows how gen- erativity results from the complex interconnections among societal and inner forces. The tension between creating a product or outcome that outlives oneself and selflessly bestowing one’s efforts as a gift to the next generation (reflecting a concern for what is good for society) results in a concern for the next genera- tion and a belief in the goodness of the human enter- prise. The positive resolution of this conflict finds middle-aged adults developing a generative com- mitment that produces generative actions. A person derives personal meaning from being generative by constructing a life story or narration that helps create the person’s identity.
Figure 9.1 McAdams’ model of generativity. Source: McAdams, D. P., Hart, H. M., & Maruna, S. (1998). The anatomy of generativity. In D. P. McAdams & E. de St. Aubin (Eds.), Generativity and Adult Development: How and Why We Care for the Next Generation (p. 7).
Motivational sources
Thoughts, plans Behavior Meaning
Cultural demand
Concern (for the next generation)
Commitment
Action • creating • maintaining • offering
Inner desire • symbolic immortality • “need to be needed”
Belief “in the species”
N a r r a t i o n
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magazines. This is in contrast to the large databases used to test the five-factor model. These theories are associated with psychometrically sound measures and are well researched. Thus, the research methods used in studies of life transitions are questionable. Still, the intuitive appeal of these theories makes them worth a closer look.
An important question about life transition the- ories is the extent they are real and actually occur to everyone. Life transition theories typically present stages as if everyone universally experiences them. Moreover, many have specific ages tied to specific stages (such as age- 30 or age- 50 transitions). As we know from cognitive developmental research reviewed in Chapter 7 , this is a tenuous assump- tion. Individual variation is the rule, not the excep- tion. What actually happens may be a combination of expectations and socialization. Dunn and Merriam (1995) examined data from a large, diverse national sample and found less than 20 % of people in their early 30 s experienced the age- 30 transition (which encompasses the midlife crisis) that forms a corner- stone of Levinson and colleagues’ (1978) theory. The experience of a midlife crisis, discussed next, is an excellent case in point.
In Search of the Midlife Crisis. One of the most important ideas in theories that consider the impor- tance of life transitions (subsequent to periods of sta- bility) is middle-aged adults experience a personal crisis that results in major changes in how they view themselves. During a midlife crisis, people are sup- posed to take a good hard look at themselves and, they hope, attain a much better understanding of who they are. Difficult issues such as one’s own mor- tality and inevitable aging are supposed to be faced. Behavioral changes are supposed to occur; we even have stereotypic images of the middle-aged male, like Andy, running off with a much younger female as a result of his midlife crisis. In support of this notion, Levinson and his colleagues (1978; Levinson & Levinson, 1996) write that middle-aged men in his study reported intense internal struggles much like depression.
However, far more research fails to document the existence, and more importantly, the universality of a
any other age. Schoklitsch & Bauman (2012) point out the capacity of generativity peaks during midlife, but people continue to accomplish generative tasks into late life (e.g., great-grandparenthood).
These data demonstrate the personal concerns of middle-aged adults are fundamentally different from those of younger adults. In fact, generativity may be a stronger predictor of emotional and physical well- being in midlife and old age (Gruenewald, Liao, & Seeman, 2012; McAdams & Olson, 2010; Wilt et al., 2010). Among women and men, generativity is asso- ciated with positive emotion and satisfaction with life and work, and predicts physical health. Considered together, these findings provide considerable support for Erikson’s contention the central concerns for adults change with age. However, the data also indicate gen- erativity is much more complex than Erikson origi- nally proposed and, while peaking in middle age, may not diminish in late life.
Theories Based on Life Transitions Jung’s belief in a midlife crisis and Erikson’s belief per- sonality development proceeds in stages laid the foun- dation for other theorists’ efforts. For many laypeople, the idea adults go through an orderly sequence of stages that includes both crises and stability reflects their own experience. This is probably why books such as Sheehy’s Passages (1976), Pathfinders (1981), New Passages (1995), and Understanding Men’s Pas- sages (1998) met with instant acceptance, or why Levinson’s (Levinson et al., 1978) and Vaillant’s works (Vaillant, 1977; Vaillant & Vaillant, 1990) have been applied to everything from basic personality devel- opment to understanding how men’s occupational careers change.
A universal assumption of these theories is people go through predictable age-related crises. Some life transition theories (e.g., Levinson’s) also propose these crises are followed by periods of relative stability. The overall view is adulthood consists of a series of alter- nating periods of stability and change.
Compared with the theories we considered to this point, however, theories based on life transitions are built on shakier ground. Some are based on small, highly selective samples (such as men who attended Harvard) or surveys completed by readers of particular
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appropriately considered a midlife correction , reevalu- ating one’s roles and dreams and making the necessary corrections.
Perhaps the best way to view midlife is as a time of both gains and losses (Lachman 2004). That is, the changes people perceive in midlife can be viewed as representing both gains and losses. Competence, abil- ity to handle stress, sense of personal control, purpose in life, and social responsibility are all at their peak, whereas physical abilities, such as women’s ability to bear children, and physical appearance in men and women are examples of changes many view as nega- tive. This gain–loss view emphasizes two things. First, the exact timing of change is not fixed but occurs over an extended period of time. Second, change can be both positive and negative at the same time. Thus, rather than seeing midlife as a time of crisis, one may want to view it as a period when several aspects of one’s life acquire new meanings.
Finally, we cannot overlook examining midlife crises from a cross-cultural perspective (Tanner & Arnett, 2009). Menon and Shweder (1998; Menon, 2001; Sterns & Huyck, 2001) suggest midlife crisis is a cultural invention. They present anthropological evidence suggesting the concept of midlife itself is limited to adults studied in the United States. In other cultures, transitions and crises are linked to role rela- tions such as marriage and relocation into the spouse’s family. Major transitions are defined by such events as children’s marriages and mothers-in-law moving into the older adult role of observer (Menon, 2001; Tanner & Arnett, 2009). Again, this is a good reminder
particularly difficult time in midlife (Lachman, 2004). In fact, those who actually experience a crisis may be suffering from general problems of psychopathology (Goldstein, 2005; Labouvie-Vief & Diehl, 1999). Stud- ies extending Levinson’s theory to women have not found strong evidence of a traumatic midlife crisis either (Harris et al., 1986; Reinke et al., 1985; Roberts & Newton, 1987).
Researchers point out the idea of a midlife crisis became widely accepted as fact because of the mass media (Sterns & Huyck, 2001). People take it for granted they will go through a period of intense psy- chological turmoil in their 40 s.
The problem is there is little hard scientific evi- dence of it. The data suggest midlife is no more or no less traumatic for most people than any other period in life. Perhaps the most convincing support for this conclusion comes from research conducted by Farrell and Rosenberg (Rosenberg et al., 1999). These inves- tigators initially set out to prove the existence of a midlife crisis because they were firm believers in it. After extensive testing and interviewing, they emerged as nonbelievers.
However, Labouvie-Vief and colleagues (e.g., Labouvie-Vief & Diehl, 1999; Labouvie-Vief et al., 2009; Grühn et al., 2013) offer good evidence for a reorganization of self and values across the adult life span. They suggest the major dynamic that drives such changes may not be age dependent, but follow general cognitive changes. As discussed in Chapter 8 , indi- viduals around middle adulthood show the most com- plex understanding of self, emotions, and motivations. Cognitive complexity also is shown to be the strongest predictor of higher levels of complexity in general. From this approach, a midlife “crisis” may be the result of general gains in cognitive complexity from early to middle adulthood.
Abigail Stewart (Newton & Stewart, 2012; Peterson & Stewart, 1996; Torges, Stewart, & Duncan, 2008) found that women who have regrets about adopting traditional roles (e.g., wife/mother) but later pursue an education or career at midlife report higher well- being than either women who experience regret but do not make a change or women who never experi- enced regrets about their roles. Stewart suggests rather than a midlife crisis, such an adjustment may be more
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260 CHAPTER 9
way she will meet a great guy she will marry soon after graduation. They will have two children before she turns 30 . Antje sees herself getting a good job teaching preschool children and someday owning her own day care center.
Who are you? What kind of person are you try- ing to become? These are the kinds of questions Antje is trying to answer. Answering these questions requires concepts of personality going beyond dis- positional traits and personal concerns. The aspects of personality we discussed thus far are important, but they lack a sense of integration, unity, coherence, and overall purpose (McAdams & Olson, 2010). For example, understanding a person’s goals (from the level of personal concerns) does not reveal who a person is trying to be, or what kind of person the person is trying to create. What is lacking in other levels of analysis is a sense of the person’s identity or sense of self.
In contrast to Erikson’s (1982) proposition that identity formation is the central task of adolescence, many researchers now believe the important ways identity and the creation of the self continue to develop throughout adulthood (e.g., Graham & Lachman, 2012; Grühn et al., 2013; Newton & Stewart, 2012). This emerging field of how adults continue construct- ing identity and the self relies on life narratives, or the internalized and evolving story that integrates a per- son’s reconstructed past, perceived present, and antici- pated future into a coherent and vitalizing life myth (Cox & McAdams, 2012; Curtin & Stewart, 2012). Careful analysis of people’s life narratives provides insight into their identity.
In this section, we consider two evolving theo- ries of identity. Dan McAdams is concerned with understanding how people see themselves and how they fit into the adult world. Susan Krauss Whit- bourne investigated people’s own conceptions of the life course and how they differ from age norms and the expectations for society as a whole. To round out our understanding of identity and the self, we also examine related constructs. Before beginning, though, take time to complete the exercise in the Discovering Development feature. This exercise will give you a sense of what a life narrative is and how it might be used to gain insight into identity and the sense of self.
the cultural context plays an important role in adult development.
Conclusions about Personal Concerns The theories and research evidence we considered show substantive change in adults’ personal concerns definitely occurs as people age. This conclusion is in sharp contrast to the stability observed in dispositional traits but does support McAdams’s (e.g., McAdams & Olson, 2010) contention this middle level of personality should show some change. What is also clear, is a tight connection between such change and specific ages is not supported by the bulk of the data. Rather, change appears to occur in wide windows of time depending on many factors, including one’s sociocultural context. Finally, more research is needed in this area, especially investigations that provide longitudinal evidence of change within individuals.
Adult Development in Action As a director of human resources at a major corpora- tion, how would knowledge about generativity help you understand your middle-aged employees better?
9.3 Life Narratives, Identity, and the Self LEARNING OBJECTIVES
What are the main aspects of McAdams’s life-story model?
What are the main points of Whitbourne’s identity theory?
How does self-concept come to take adult form? What is its development during adulthood?
What are possible selves? Do they show differences during adulthood?
What role does religion or spiritual support play in adult life?
What conclusions can be drawn from research using life narratives?
A ntje is a 19 - year-old sophomore at a community college. She expects her study of early childhood educa- tion to be difficult but rewarding. She figures along the
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PERSONALITY 261
in the wake of major and minor life changes. Genera- tivity marks the attempt to create an appealing story “ending” that will generate new beginnings for future generations.
Paramount in these life stories is the changing personal identity reflected in the emotions conveyed in the story (from tragedy to optimism or through comic and romantic descriptions). In addition, moti- vations change and are reflected in the person repeat- edly trying to attain his or her goals over time. The two most common goal themes are agency (reflecting power, achievement, and autonomy) and communion (reflecting love, intimacy, and a sense of belonging). Finally, stories indicate one’s beliefs and values, or the ideology a person uses to set the context for his or her actions.
Every life story contains episodes that provide insight into perceived change and continuity in life. People prove to themselves and others they have either changed or remained the same by pointing to specific events supporting the appropriate claim. The main characters in people’s lives represent idealizations of the self, such as “the dutiful mother” or “the reliable worker.” Integrating these various aspects of the self is a major challenge of midlife and later adulthood. Finally, all life stories need an ending so the self can leave a legacy that creates new beginnings. Life stories in middle-aged and older adults have a clear quality of “giving birth to” a new generation, a notion essentially identical to generativity.
One of the more popular methods for examin- ing the development of life stories is through auto- biographical memory (Lilgendahl & McAdams, 2011; McLean & Pasupathi, 2012). When people tell their life stories to others, the stories are a joint product of the speaker and the audience (Pasupathi, 2001, 2013; McLean & Pasupathi, 2012). Pasupathi finds the responses of the audience affect how the teller remem- bers his or her experiences. This is a good example of conversational remembering, much like collaborative cognition discussed in Chapter 8 .
Overall, McAdams (2001; McAdams & Olson, 2010) believes the model for change in identity over time is a process of fashioning and refashioning one’s life story. This process appears to be strongly influ- enced by culture. At times, the reformulation may be at a conscious level, such as when people make explicit
McAdams’s Life-Story Model McAdams (2001; Cox & McAdams, 2012; Lilgendahl & McAdams, 2011) argues a person’s sense of identity cannot be understood using the language of disposi- tional traits or personal concerns. Identity is not just a collection of traits, nor is it a collection of plans, strat- egies, or goals. Instead, it is based on a story of how the person came into being, where the person has been, where he or she is going, and who he or she will become, much like Antje’s story. McAdams argues peo- ple create a life story that is an internalized narrative with a beginning, middle, and an anticipated ending. The life story is created and revised throughout adult- hood as people change and the changing environment places different demands on them.
McAdams’s research indicates people in Western societies begin forming their life story in late ado- lescence and early adulthood, but it has roots in the development of one’s earliest attachments in infancy. As in Erikson’s theory, adolescence marks the full ini- tiation into forming an identity, and thus, a coherent life story begins. In early adulthood it is continued and refined, and from midlife and beyond it is refashioned
DISCOVERING DEVELOPMENT: WHO DO YOU WANT TO BE WHEN YOU “GROW UP”? From the time you were a child, people have posed this question to you. In childhood, you probably answered by indicating some specific career, such as firefighter or teacher. But now that you are an adult, the question takes on new meaning. Rather than simply a matter of picking a profession, the ques- tion goes much deeper to the kinds of values and the essence of the person you would like to become.
Take a few minutes and think about who you would like to be in another decade or two (or maybe even 50 years hence). What things will matter to you? What will you be doing? What experiences will you have had? What lies ahead?
This exercise can give you a sense of the way researchers try to understand people’s sense of iden- tity and self through the use of personal narrative. You might want to keep what you have written and check it when the appropriate number of years elapse.
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against where her scenario says she should be. If she achieves her goals earlier than expected, she will feel proud of being ahead of the game. If things work out more slowly than she planned, she may chastise herself for being slow. If she begins to criticize herself a great deal, she may end up changing her scenario altogether; for example, if she does not get a good job and makes no progress, she may change her scenario to one that says she should stay home with her child.
As Kim starts moving into the positions laid out in her scenario, she begins to create the second com- ponent of her life-span construct, her life story. The life story is a personal narrative history organizing past events into a coherent sequence. The life story gives events personal meaning and a sense of conti- nuity; it becomes our autobiography. Because the life story is what we tell others when they ask about our past, it eventually becomes somewhat over-rehearsed and stylized. An interesting aspect of the life story, and autobiographical memory in general, is that distortions occur with time and retelling (Lilgendahl & McAdams, 2011; McLean & Pasupathi, 2012; Pasupathi, 2001). In life stories, distortions allow the person to feel he or she was on time, rather than off time in terms of past events in the scenario. In this way, people feel better about their plans and goals and are less likely to feel a sense of failure.
Whitbourne grounded her theory on a fascinat- ing cross-sectional study of 94 adults ranging in age from 24 to 61 (Whitbourne, 1986). The subjects came from all walks of life and represented a wide range of occupations and life situations. Using data from detailed interviews, Whitbourne was able to identify what she believes is the process of adult identity devel- opment based on equilibrium between identity and experience. Her model is presented in Figure 9.2 . As the figure shows, there is continuous feedback between identity and experience; this explains why we evalu- ate ourselves positively at one point in time, yet appear defensive and self-protective at another.
As you can see, the processes of equilibrium are based on Piaget’s concepts of assimilation and accommodation (see Chapter 7 ). Whitbourne explic- itly attempted to integrate concepts from cognitive development with identity development to under- stand how identity is formed and revised across adult- hood. The assimilation process involves using already
decisions about changing careers. At other times, the revision process is unconscious and implicit, grow- ing out of everyday activities. The goal is to create a life story that is coherent, credible, open to new pos- sibilities, richly differentiated, reconciling of opposite aspects of oneself, and integrated within one’s socio- cultural context.
Whitbourne’s Identity Theory A second and related approach to understanding iden- tity formation in adulthood is Whitbourne’s (e.g., 1987, 1996c, 2010) idea that people build their own concep- tions of how their lives should proceed. The result of this process is the life-span construct , the person’s uni- fied sense of the past, present, and future.
There are many influences on the development of a life-span construct: identity, values, and social context are a few. Together, they shape the life-span construct and the ways it is manifested. The life-span construct has two structural components that in turn are the ways it is manifested. The first of these components is the scenario, consisting of expectations about the future. The scenario translates aspects of our identity that are particularly important at a specific point into a plan for the future. The scenario is strongly influenced by age norms defining key transition points; such as graduating from college, a transition normally associ- ated with the early 20 s. In short, a scenario is a game plan for how we want our lives to go.
Kim, a typical college sophomore, may have the following scenario: She expects her course of study in nursing will be difficult but she will finish on time. She hopes to meet a nice guy along the way who she will marry shortly after graduation. She imagines she will get a good job at a major medical center that offer her opportunities for advancement. She and her husband will probably have a child, but she expects to keep working. Because she feels she will want to advance, she assumes at some point she will earn a master’s degree. In the more distant future she hopes to be a department head and well respected for her adminis- trative skills.
Tagging certain expected events with a particu- lar age or time we expect to complete them creates a social clock (see Chapter 1 ). Kim will use her sce- nario to evaluate her progress toward her goals. With each major transition she will check how she is doing
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through transitions when they feel they needed to and to do so on their own time line. Whitbourne, Sneed, and Skultety (2002) developed the Identity and Experi- ences Scale–General to measure identity processes in adults. This scale assesses an individual’s use of assimi- lation and accommodation in forming identity in a general sense, and is based on her earlier work. Her model has expanded to incorporate how people adapt more generally to middle age and the aging process (Whitbourne, 2010).
In a series of studies, Whitbourne (e.g., Sneed & Whitbourne, 2003, 2005) reported identity assimila- tion and identity accommodation change with age. Identity assimilation was higher in older adulthood and identity accommodation was higher in younger adulthood. Furthermore, identity assimilation in older adulthood was associated with maintaining and enhancing positive self-regard through the minimi- zation of negativity. In contrast, a changing identity (e.g., through accommodation) in older adulthood was associated more with poor psychological health. The ability to integrate age-related changes into one’s identity and maintain a positive view of oneself is crucial to aging successfully (Whitbourne, 2010). This suggests people make behavioral adjustments to promote healthy adaptation to the aging process (see Chapter 3 ).
existing aspects of identity to handle present situations. Over-reliance on assimilation makes the person resis- tant to change. Accommodation, in contrast, reflects the willingness of the individual to let the situation determine what he or she will do. This often occurs when the person does not have a well-developed iden- tity around a certain issue.
Not surprisingly, Whitbourne found the vast majority of adults listed family as the most important aspect of their lives. Clearly, adults’ identity as a loving person constitutes the major part of the answer to the question “Who am I?” Consequently, a major theme in adults’ identity development is refining their belief that “I am a loving person.” Much of this development is based in acquiring and refining deep, emotional relationships.
Another major source of identity for Whitbourne’s participants was work. In this case, the key seemed to be keeping work interesting. As long as individuals had an interesting occupation that enabled them to become personally invested, their work identity was more cen- tral to their overall personal identity. This is a topic we pursue in Chapter 12 .
Although Whitbourne found evidence of life tran- sitions, overall she found scant evidence these tran- sitions occurred in a stage-like fashion or were tied to specific ages. Rather, she found people tend to go
Figure 9.2 Whitbourne’s model of adult identity processes. Source: Whitbourne, S. K. (1986). The psychological construction of the life span. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the Psychology of Aging (pp. 594–619). New York: Van Nostrand Reinhold. All rights reserved. Reproduced by permission of the author.
Identity “I am a loving, competent, and
good person.”
Experience The “me” as experienced in family,
work, and other social roles
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Self-evaluation and considering alternatives
Identity Assimilation
Self-justification, defensive rigidity, lack of insight, and identity projection
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264 CHAPTER 9
(1997, 2003, 2005). She argues the self is a product of the integration of emotion and cognition, topics we explored in Chapters 7 and 8 .
For Labouvie-Vief, the integration of the optimi- zation of happiness and the ability to tolerate tension and negativity to maintain objectivity that creates a healthy self-concept in adulthood. She builds the case the dynamic integration of this optimization and dif- ferentiation is what creates a healthy balance. The abil- ity to accomplish this integration increases from young through middle adulthood, but decreases in late life.
This point was clearly demonstrated by Labouvie- Vief and colleagues (1995). Working within a cognitive- developmental framework, they documented age differences in self-representation in people ranging in age from 11 to 85 years. Specifically, they found mature adults move from representations of the self in young adulthood that are relatively poorly differentiated from others or from social conventions and expectations, to highly differentiated representations in middle age, to less differentiated representations in old age. An important finding was the degree of differentiation in self-representation was related to the level of cognitive development, thereby providing support for Kegan’s position.
Other Research on Self-Concept. In addition to research integrating cognitive and emotional devel- opment, researchers also focused on other sources for creating the self across adulthood. In Chapter 8 , we saw the incorporation of aging stereotypes strongly influ- ences people’s self-concept (e.g., Kornadt & Rother- mund, 2012; Weiss & Lang, 2012).
Some research documents how people organize the various facets of their self-concept. That research shows older adults compartmentalize the different aspects of self-concept (e.g., various positive and nega- tive aspects) more than either younger or middle-aged adults (Ready, Carvalho, & Åkerstedt, 2012).
In general, research examining self-concept shows it is significantly related to a wide variety of variables such as health and longevity. We return to this issue in Chapter 14 when considering successful aging.
Well-Being and Emotion. How is your life going? Are you reasonably content, or do you think you could be doing better? Answers to these questions provide
Self-Concept and Well-Being As we have seen, an important aspect of identity in adulthood is how one integrates various aspects of the self. Self-perceptions and how they differ with age have been examined in a wide variety of studies and are related to many behaviors. Changes in self- perceptions are often manifested in changed beliefs, concerns, and expectations. Self-concept is the orga- nized, coherent, integrated pattern of self-perceptions. Self-concept includes the notions of self-esteem and self-image.
Kegan’s Theory of Self-Concept. Kegan (1982, 1994, 2009) attempted to integrate the development of self- concept and cognitive development. He postulated six stages of the development of self, corresponding to stages of cognitive development described in Chapter 7 . Kegan’s first three stages—incorporative, impulsive, and imperial—correspond to Piaget’s sensorimotor, preoperational, and concrete operational stages (see Chapter 7 ). During this time, he believes children move from knowing themselves on the basis of reflexes to knowing themselves through needs and interests.
He argues at the beginning of formal operational thought during early adolescence (see Chapter 7 ), a sense of interpersonal mutuality begins to develop; he terms this period the interpersonal stage. By late ado- lescence or young adulthood, people move to a mature sense of identity based on taking control of their own life and developing an ideology; Kegan calls this period the institutional stage.
Finally, with the acquisition of post-formal thought (see Chapter 7 ) comes an understanding that the self is a complex system that takes into account other people; Kegan terms this period the interindividual stage.
Kegan’s work emphasizes that personality devel- opment does not occur in a vacuum. Rather, we must remember a person is a complex integrated whole. Consequently, an understanding of the development of self-concept or any other aspect of personality is enhanced by an understanding of how it relates to other dimensions of development.
Labouvie-Vief’s Dynamic Integration Theory. The integration of cognitive and personality development has also been a major focus of Gisela Labouvie-Vief
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PERSONALITY 265
play a key role in understanding emotional regulation in older adults. Here’s how. In young adults, arousal of the amygdala is associated with negative emotional arousal. When negative emotional arousal occurs, memory for events associated with the emotion are stronger. But the situation is different for older adults—both amygdala activation and emotional arousal are lower. That may be one reason why older adults experience less negative emotion, lower rates of depression, and better well-being (Cacioppo et al., 2011; Winecoff et al., 2011).
That’s not the whole story. As described in Chapter 2 , neuroimaging research shows changes in cognitive processing in the prefrontal cortex is also associated with changes in emotional regulation in older adults. Understanding the brain’s role in emo- tion requires us to take a closer look at what’s really going on inside the prefrontal cortex. The How Do We Know? feature provides insight into that issue and sheds light onto key differences in brain processing of emotion in people with depression.
insight into your subjective well-being , an evaluation of one’s life associated with positive feelings . Subjec- tive well-being is usually assessed by measures of life satisfaction, happiness, and self-esteem (Oswald & Wu, 2010).
Overall, young-older adults are characterized by improved subjective well-being compared to earlier in adulthood (Charles & Carstensen, 2010). The dif- ferences in people’s typical level of happiness across adulthood are illustrated in results from the United Kingdom, shown in Figure 9.3 . These happiness-related factors hold across cultures as well; a study of Taiwanese and Tanzanian older adults showed similar predictors of successful aging (Hsu, 2005; Mwanyangala et al., 2010).
Emotion-focused research in neuroscience pro- vides answers to the question of why subjective well-being tends to increase with age (Cacioppo et al., 2011). A brain structure called the amygdala, an almond-shaped set of nuclei deep in the brain, helps regulate emotion. Evidence is growing that age- related changes in how the amygdala functions may
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5.6 Figure 9.3 The pattern of a typical person’s happiness through life in the United Kingdom. Source: From Happiness, health, and economics , by A. Oswald. Copyright © Warwick University. http://imechanica.org/files/andrew_oswald_ presentation_071129.pdf.
HOW DO WE KNOW?: WELL-BEING REFLECTED IN BRAIN FUNCTION IN EMOTION AND DEPRESSION Who was the investigator, and what was the aim of the study? How emotions get processed in the brain play an important role in determining a person’s over- all well-being. Although evidence from EEG studies
demonstrated abnormal asymmetries in the frontal cortex in the processing of emotions between people who were and were not depressed, fMRI and PET stud- ies failed to identify specific pathways underlying these differences. Herrington, Heller, Mohanty, Engels, Barich, Webb, and colleagues (2010) set out to discover these underlying paths.
How did the investigators measure the topic of interest? The researchers carefully screened a large
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266 CHAPTER 9
sample to ensure one group had only depression (and no significant levels of anxiety or other men- tal health problem) and the control group had no significant signs of any mental health problem. This was determined with a series of questionnaires.
While participants were in the fMRI machine, they were given two tasks, the emotion-word Stroop and the color-word Stroop. Both tasks involved participants stating the color of ink in which words were printed. In the emotion-word Stroop, pleasant, unpleasant, and neutral emotion words were printed in one of four color inks. For the color-word task, the words were the four color names printed in the four different colors. The key measure was the speed of response in saying the color of the ink.
Who were the participants in the study? 1688 young adults were screened to create a group of 29 , 11 had depression and 18 served as controls.
Were there ethical concerns with the study? All participants were volunteers and provided written consent under a protocol approved by the Institu- tional Review Board.
What were the results? Reaction times were longer for pleasant and unpleasant words com- pared to neutral words, and longer for pleasant
than unpleasant words. These findings are shown in Figure 9.4 .
Examination of the fMRI data revealed there were significant differences between the groups in how emotional information was processed in the brain. Differences are shown in Figure 9.5 . The key finding from frontal lobe and amygdala activation data is participants with depression showed significantly greater lateralization, that is, separate areas of processing for pleasant and unpleasant words, than did participants who did not have depression.
What did the investigators conclude? Her- rington and colleagues concluded there is struc- tural brain evidence for abnormal asymmetric processing in the frontal brain region and in the amygdala for emotional information in individu- als with depression. This indicates that atten- tional processing (that heavily involves the frontal region) likely plays a role in depression and the processing of emotional material. These findings open possibilities for understanding the connec- tions between emotional processing and well- being, as well as potential approaches to treating depression through focusing on specific neural pathways.
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Figure 9.4 Response times for pleasant, neutral, and unpleasant words. Error bars represent 1 standard deviation above and below the mean. Source: Herrington, J. D., Heller, W., Mohanty, A., Engels, A. S., Barich, M. T., Webb, A. G., et al. (2010). Localization of asymmetric brain function in emotion and depression. Psychophysiology, 47, 442–454. doi: 10.1111/j.1469-8986.2009.00958.x. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles /PMC3086589/. (Figure 1)
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PERSONALITY 267
Figure 9.5 Areas yielding a Significant Valence × Hemisphere interactions in middle (top) and superior (bottom) frontal gyri, and peri-amygdala. The left-hand column displays the clusters. Activation is arbitrarily overlaid on left-hemisphere anatomy, as hemisphere was included as a factor in the analysis. The red crosshairs are placed over the center of effect size for each cluster. The right column plots mean parameter estimates (i.e., the average of all voxel values within the cluster) for each level of valence and hemisphere averaged across both groups. Although these regions did not show a three-way interaction involving Group, the middle column contains plots of the average parameter estimates for each level of Group separately. Error bars represent 1 standard error above and below the mean. Source: Herrington, J. D., Heller, W., Mohanty, A., Engels, A. S., Barich, M. T., Webb, A. G., et al. (2010). Localization of asymmetric brain function in emotion and depression. Psychophysiology, 47, 442–454. doi: 10.1111/j.1469-8986.2009.00958.x. Retrieved from http://www.ncbi.nlm.nih.gov /pmc/articles/PMC3086589/. (Figure 2)
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268 CHAPTER 9
Possible Selves When we are asked questions like, “What do you think you’ll be like a few years from now?” it requires us to imagine ourselves in the future. When we speculate like this, we create a possible self (Markus & Nurius, 1986). Possible selves represent what we could become, what we would like to become, and what we are afraid of becoming . What we could or would like to become often reflects personal goals; we may see ourselves as leaders, as rich and famous, or in great physical shape. What we are afraid of becoming may show up in our fear of being alone, or overweight, or unsuccessful. Our possible selves are powerful motivators; indeed, how we behave is largely an effort to achieve or avoid these various possible selves and protect the current view of self (Baumeister, 2010).
Researchers examined age differences in the con- struction of possible selves (Bardach et al., 2010; Cotter & Gonzalez, 2009). In a rare set of similar studies con- ducted across time and research teams by Cross and Markus (1991) and Hooker and colleagues (Frazier et al., 2000, 2002; Hooker, 1999; Hooker et al., 1996; Morfei et al., 2001), people across the adult life span were asked to describe their hoped-for and feared–possible selves. The responses were grouped into categories (e.g., fam- ily, personal, material, relationships, and occupation).
Several interesting age differences emerged. In terms of hoped-for selves, young adults listed family concerns—for instance, marrying the right person—as most important. In contrast, adults in their 30 s listed family concerns last; their main issues involved per- sonal concerns, such as being a more loving and caring person. By ages 40 to 59 , family issues again became most common—such as being a parent who can “let go” of the children. Reaching and maintaining satisfac- tory performance in one’s occupational career as well as accepting and adjusting to the physiological changes of middle age were important to this age group.
For adults over 60 , researchers find personal issues are most prominent—like being active and healthy for at least another decade. The greatest amount of change occurred in the health domain, which predominated the hoped-for and feared-for selves. The health domain is the most sensitive and central to the self in the context of aging and people’s possible self with regard to health is quite resilient in the face of health challenges in later life.
Overall, young adults have multiple possible selves and believe they can actually become the hoped-for self and successfully avoid the feared–self. Their outlook tends to be quite positive (Remedios, Chasteen, & Packer, 2010). Life experience may dampen this outlook. By old age, both the number of possible selves and the strength of belief have decreased. Older adults are more likely to believe neither the hoped-for nor the feared-for self is under their personal control. These findings may reflect differences with age in personal motivation, beliefs in personal control, and the need to explore new options.
The emergence of online social media has created new opportunities for young adults to create possible selves (Lefkowitz, Vukman, & Loken, 2012). Such media present different ways for them to speculate about themselves to others.
Religiosity and Spiritual Support When faced with the daily problems of living, how do older adults cope? Older adults in many countries use their religious faith and spirituality, more often than they use family or friends (Ai, Wink, & Ardelt, 2010). For some older adults, especially African Ameri- cans, a strong attachment to God is what they believe helps them deal with the challenges of life (Dilworth- Anderson, Boswell, & Cohen, 2007).
There is considerable evidence linking spiritual- ity and health (Krause, 2006; Park, 2007). In general, older adults who are more involved with and commit- ted to their faith have better physical and mental health than older adults who are not religious (Ai et al., 2010). For example, older Mexican Americans who pray to the saints and the Virgin Mary on a regular basis tend to have greater optimism and better health (Krause & Bastida, 2011).
When asked to describe ways of dealing with prob- lems in life that affect physical and mental health, many people list coping strategies associated with spiritual- ity (Ai et al., 2010; White, Peters, & Schim, 2011). Of these, the most frequently used were placing trust in God, praying, and getting strength and help from God.
Researchers have increasingly focused on spiritual support —meaning they seek pastoral care, participate in organized and nonorganized religious activities, and express faith in a God who cares for people—as a key fac- tor in understanding how older adults cope . Even when
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PERSONALITY 269
under high levels of stress people who rely on spiritual support report greater personal well-being (Ai et al., 2010; White et al., 2011). Krause (2006) reports feel- ings of self-worth are lowest in older adults who have very little religious commitment, a finding supported by cross-cultural research with Muslims, Hindus, and Sikhs (Mehta, 1997).
When people rely on spirituality to cope, how do they do it? Krause and colleagues (2000) found older adults reported turning problems over to God really was a three-step process: (1) differentiating between things that can and cannot be changed; (2) focusing one’s own efforts on the parts of the problem that can be changed; and (3) emotionally disconnecting from those aspects of the problem that cannot be changed by focusing on the belief that God provides the best outcome possible for those. These findings show reliance on spiritual beliefs acts to help people focus their attention on parts of the problem that may be under their control.
Reliance on religion in times of stress appears to be especially important for many African Americans, who as a group are more intensely involved in religious activities (Taylor, Chatters, & Levin, 2004; Troutman et al., 2011). They also are more likely to rely on God for support than are European Americans (Lee & Sharpe, 2007). Churches have historically offered considerable social support for the African American community, served an important function in advocating social justice, and ministers play a major role in providing support in times of personal need (Chatters et al., 2011).
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Similar effects of spirituality are observed in Asian and Asian American groups. The risk of dying in a given year among the old-old in China was found to be 21 % lower among frequent religious participants compared to nonparticipants, after initial health condition was equated (Zeng, Gu, & George, 2011). Asian caregivers of dementia patients who are more religious report being able to handle the stresses and burden of caregiving bet- ter than nonreligious caregivers (Chan, 2010).
And neuroscience research shows there is a con- nection between certain practices and brain activity. There is evidence that people who practice meditation show more organized attention systems and less activ- ity in areas of the brain that focus on the self (Davidson, 2010; Lutz et al., 2009). Thus, neurological evidence indicates there may be changes in brain activity associ- ated with spiritual practices that help people cope.
Health care and social service providers would be well advised to keep in mind the self-reported impor- tance of spirituality in the lives of many older adults when designing interventions to help them adapt to life stressors. For example, older adults may be more willing to talk with their minister or rabbi about a personal problem than they would be to talk with a psychotherapist. Overall, many churches offer a wide range of programs to assist poor or homebound older adults in the community. Such programs may be more palatable to the people served than programs based in social service agencies. To be successful, service pro- viders should try to view life as their clients see it.
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270 CHAPTER 9
Conclusions about Narratives, Identity, and the Self
We have seen to fully understand a person, we must consider how the individual integrates his or her life into a coherent structure. The life-narrative approach provides a way to learn how people accomplish this integration. The theoretical frameworks developed by McAdams and by Whitbourne offer excellent avenues for research. One of the most promising new areas of inquiry, possible selves, is already providing major insights into how people construct future elements of their life stories.
When combined with the data from the disposi- tional trait and personal concerns literatures, research findings on identity and the self, provide the capstone knowledge needed to understand what people are like. The complexity of personality is clear from this discus- sion; perhaps that is why it takes a lifetime to complete.
SOCIAL POLICY IMPLICATIONS Throughout this chapter, we emphasized that all aspects of personality interact in complex ways, and are inextricably linked to other aspects of develop- ment (e.g., cognitive development). What we have not examined is the extent to which external forces, such as public policy decisions at the societal level, can affect aspects of personality.
An intriguing analysis of this issue was done in Bei- jing by Sun and Xiao (2012). They examined the effects perceived fairness of certain social policies on social security and income distribution had on participants’ well-being. Based on a survey of over 2100 residents of Beijing, they found perceived fairness of these policies were positively associated with well-being.
Similarly, Raju (2011) points out social policy in developing countries has a profound effect on the well- being of the rapidly increasing aging populations there. In the case of India, Raju argues health care policy in
particular will be an important need in order to maxi- mize the odds that people age successfully.
These studies highlight an increasingly important consideration—that government policies can affect how people’s experience of aging actually occurs. Posi- tive government policies that provide the support and services necessary can improve well-being and the like- lihood people age successfully. The reverse also appears to be true—that failure to enact such policies has a del- eterious effect on people as they age.
We will see in Chapter 14 the United States faces its own challenges with respect to ensuring the needed financial and health supports will be available through Social Security and Medicare. However, the low degree baby boomers are actually prepared for late life (e.g., because of lack of retirement savings) may mean their experience will not live up to their expectations. If that’s true, then their well-being may suffer.
Adult development in action If you were part of a multidisciplinary support team, how would you include spirituality as part of an over- all plan to help your clients cope with life issues?
Summary 9.1 Dispositional Traits across Adulthood
What is the five-factor model of dispositional traits? The five-factor model posits five dimensions of
personality: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Each of these dimensions has several descriptors.
Several longitudinal studies indicate personality traits show long-term stability.
What happens to dispositional traits across adulthood? Studies find evidence for change in Big Five fac-
tors such as neuroticism, agreeableness, conscien- tiousness, and extraversion. These are related to two dimensions of personality: adjustment and growth.
Both stability and change characterize personality development in advanced old age.
Several criticisms of the five-factor model have been made: The research may have methodologi- cal problems; dispositional traits do not describe
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PERSONALITY 271
the core aspects of human nature and do not provide good predictors of behavior; and disposi- tional traits do not consider the contextual aspects of development.
An intraindividual perspective challenges stability by examining personality at the level of the indi- vidual.
What conclusions can we draw about dispositional traits?
The bulk of the evidence suggests dispositional traits are relatively stable across adulthood, but there may be a few exceptions. Criticisms of the research point to the need for better statistical analyses and a determination of the role of life experiences.
Stability in personality traits may be more evident later in the life span.
9.2 Personal Concerns and Qualitative Stages in Adulthood
What’s different about personal concerns? Personal concerns take into account a person’s
developmental context and distinguish between “having” traits and “doing” everyday behaviors. Personal concerns entail descriptions of what peo- ple are trying to accomplish and the goals they create.
What are the main elements of Jung’s theory? Jung emphasized various dimensions of personal-
ity (masculinity–femininity; extraversion–introver- sion). Jung argues people move toward integrating these dimensions as they age, with midlife being an especially important period.
What are the stages in Erikson’s theory? The sequence of Erikson’s stages is trust versus mis-
trust, autonomy versus shame and doubt, initia- tive versus guilt, industry versus inferiority, identity versus identity confusion, intimacy versus isolation, generativity versus stagnation, and ego integ- rity versus despair. Erikson’s theory can be seen as a trust-achievement-wholeness cycle repeating twice, although the exact transition mechanisms have not been clearly defined.
Generativity has received more attention than other adult stages. Research indicates generative concern and generative action can be found in all age groups of adults, but they are particularly apparent among middle-aged adults.
What are the main points and problems with theories based on life transitions?
In general, life transition theories postulate periods of transition that alternate with periods of stability. These theories tend to overestimate the common- ality of age-linked transitions.
Research evidence suggests crises tied to age 30 or the midlife crisis do not occur for most people. How- ever, most middle-aged people do point to both gains and losses that could be viewed as change.
A midlife correction may better characterize this transition for women.
What can we conclude about personal concerns? Theory and research both provide support for
change in the personal concerns people report at various times in adulthood.
9.3 Life Narratives, Identity, and the Self
What are the main aspects of McAdams’s life-story model?
McAdams argues that people create a life story as an internalized narrative with a beginning, mid- dle, and anticipated ending. An adult reformulates that life story throughout adulthood. The life story reflects emotions, motivations, beliefs, values, and goals to set the context for his or her behavior.
What are the main points of Whitbourne’s identity theory?
Whitbourne believes people have a life-span con- struct: a unified sense of their past, present, and future. The components of the life-span construct are the scenario (expectations of the future) and the life story (a personal narrative history). She integrates the concepts of assimilation and accom- modation from Piaget’s theory to explain how peo- ple’s identity changes over time. Family and work are two major sources of identity.
What is self-concept and how does it develop in adulthood?
Self-concept is the organized, coherent, integrated pattern of self-perception. The events people experience help shape their self-concept. Self- presentation across adulthood is related to cognitive- developmental level. Self-concept tends to stay stable at the group mean level.
What are possible selves and how do they show differences during adulthood?
People create possible selves by projecting them- selves into the future and thinking about what they
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272 CHAPTER 9
would like to become, what they could become, and what they are afraid of becoming.
Age differences in these projections depend on the dimension examined. In hoped-for selves, young adults and middle-aged adults report family issues as most important, whereas 25 - to 39 - year- olds and older adults consider personal issues to be most important. However, all groups include physical aspects as part of their most feared pos- sible selves.
Although younger and middle-aged adults view themselves as improving, older adults view them- selves as declining. The standards by which people judge themselves change over time.
What role does religion or spiritual support play in adult life?
Older adults use religion and spiritual support more often than any other strategy to help them cope with problems in life. This provides a strong influence on identity. This is especially true for Afri- can American women, who are more active in their church groups and attend services more frequently. Other ethnic groups also gain important aspects of identity from religion.
What conclusions can we draw about narratives, identity, and the self?
The life-narrative approach provides a way to learn how people integrate the various aspects of their personality. Possible selves, religiosity, and gen- der-role identity are important areas in need of additional research.
Review Questions 9.1 Dispositional Traits across Adulthood
What is a dispositional trait? Describe Costa and McCrae’s five-factor model
of personality. What are the descriptors in each dimension? How do these dimensions change across adulthood?
What evidence is there in other longitudinal research for change in personality traits in adult- hood? Under what conditions is there stability or change?
What are the specific criticisms raised concerning the five-factor model?
What does most of the evidence say about the sta- bility of dispositional traits across adulthood?
9.2 Personal Concerns and Qualitative Stages in Adulthood
What is meant by a personal concern? How does it differ from a dispositional trait?
Describe Jung’s theory. What important develop- mental changes did he describe?
Describe Erikson’s eight stages of psychosocial devel- opment. What cycles have been identified? How has his theory been clarified and expanded? What types of generativity have been proposed? What evi- dence is there for generativity? What modifications to Erikson’s theory has this research suggested?
What are the major assumptions of theories based on life transitions? What evidence is there a midlife crisis really exists? How can midlife be viewed from a gain–loss perspective?
Overall, what evidence is there for change in per- sonal concerns across adulthood?
9.3 Life Narratives, Identity, and the Self What are the basic tenets of McAdams’s life-story
theory? What are the seven elements of a life story? What is Whitbourne’s life-span construct? How
does it relate to a scenario and a life story? How did Whitbourne incorporate Piagetian concepts into her theory of identity?
What is self-concept? What shapes it? What are possible selves? What developmental
trends have been found in possible selves? How are religiosity and spiritual support important
aspects of identity in older adults?
INTEGRATING CONCEPTS IN DEVELOPMENT What relations can be found among dispositional
traits, personal concerns, and life narratives? How does personality development reflect the four
basic forces of development discussed in Chapter 1 ? How does cognitive development relate to person-
ality change? How does personality change relate to stages in
occupational transition?
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PERSONALITY 273
KEY TERMS cognitive processes A structural component of personality that acts jointly with life narratives to create natural interactions between a storyteller and listener, processes central in organizing life stories.
dispositional trait A relatively stable, enduring aspect of personality.
ego development The fundamental changes in the ways our thoughts, values, morals, and goals are organized. Transitions from one stage to another depend on both internal biological changes and external social changes to which the person must adapt.
epigenetic principle In Erikson’s theory, the notion that development is guided by an underlying plan in which certain issues have their own particular times of importance.
five-factor model A model of dispositional traits with the dimensions of neuroticism, extraversion, open- ness to experience, agreeableness–antagonism, and conscientiousness–undirectedness.
life narrative The aspects of personality that pull everything together, those integrative aspects that give a person an identity or sense of self.
life-span construct In Whitbourne’s theory of identity, the way people build a view of who they are.
midlife correction Reevaluating one’s roles and dreams and making the necessary corrections.
personal concerns Things that are important to people, their goals, and their major concerns in life.
personality adjustment Involves developmental changes in terms of their adaptive value and function- ality such as functioning effectively within society and how personality contributes to everyday life running smoothly.
personality growth Refers to ideal end states such as increased self-transcendence, wisdom, and integrity.
possible selves Aspects of the self-concept involving oneself in the future in both positive and negative ways.
self-concept The organized, coherent, integrated pat- tern of self-perceptions.
spiritual support Includes seeking pastoral care, participating in organized and nonorganized religious activities, and expressing faith in a God who cares for people as a key factor in understanding how older adults cope.
state processes A structural component of personality that acts with dispositional traits to create transient, short-term changes in emotion, mood, hunger, anxiety, etc.
subjective well-being An evaluation of one’s life that is associated with positive feelings.
trait Any distinguishable, relatively enduring way in which one individual differs from others.
trait theories Theories of personality that assume little change occurs across adulthood.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL
DISORDERS
10.1 MENTAL HEALTH AND THE ADULT LIFE COURSE Defining Mental Health and Psychopathology • A Multidimensional Life-Span Approach to Psychopathology • Ethnicity, Gender, Aging, and Mental Health
10.2 DEVELOPMENTAL ISSUES IN ASSESSMENT AND THERAPY Areas of Multidimensional Assessment • Factors Influencing Assessment • Assessment Methods • Developmental Issues in Therapy
10.3 THE BIG THREE: DEPRESSION, DELIRIUM, AND DEMENTIA Depression • Delirium • Dementia • Current Controversies: New Diagnostic Criteria for Alzheimer’s Disease • How Do We Know?: Training Persons with Dementia to Be Group Activity Leaders
10.4 OTHER MENTAL DISORDERS AND CONCERNS Anxiety Disorders • Psychotic Disorders • Substance Abuse • Discovering Development: What Substance Abuse Treatment Options Are Available in Your Area?
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 10
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 275
Although The Incidence Of Many Diseases Often Varies Across Socioeconomic Class, Dementia does not. It does not care whether you are rich and famous. As evidence, Rosa Parks, Ronald Reagan, and Margaret Thatcher are three major historical figures to have been diagnosed with dementia. As the person who started the modern civil rights movement by refus- ing to give up her seat on a bus in Montgomery, Alabama, in 1955, Rosa Parks (1913–2005) became a major national figure and her action launched the career of Rev. Martin Luther King, Jr. For the rest of her life she championed the cause of equal rights.
Ronald Reagan (1911–2004) was the oldest man elected as president of the United States, winning election to his first term at age 69 and to his second term at age 73 . He served as the 40 th president from 1981 to 1989. As a well-known actor and two-term governor of California, Reagan had broad experience in the limelight. Enormously popular during his tenure, Reagan presided over the United States at a time of major global change. He is still remembered and respected by millions of people for his actions during his presidency. Shortly after he left office, however, Reagan began to experience serious memory difficulties along with other health problems. Eventually he was diag- nosed with Alzheimer’s disease and his condition slowly deteriorated as the disease progressed.
Margaret Thatcher (1925–2013) was the first woman to serve as Prime Minister of Great Britain, holding that office from 1979 to 1990. A political conservative who was closely aligned with President Reagan, Prime Minister Thatcher was well known for instituting many economic changes in Britain and for her staunchly anti-communist stance. She built strong relations with the United States, par- ticularly on issues related to the Soviet Union. Lady Thatcher’s cognitive problems were revealed by her daughter in 2008, and were an important part of the biographical film The Iron Lady .
In this chapter, we consider situations such as those of Rosa Parks, Ronald Reagan, and Margaret Thatcher in which the aging process goes wrong. Such problems happen to families every day across all demographic categories. Certainly, Alzheimer’s disease is not part of normal aging, nor are the other problems we consider.
This chapter is about the people who do not make it through adulthood to old age by only experiencing normative physiological changes (see Chapters 3 and 4 ). A minority of adults develop mental health difficulties that cause them problems in their daily lives and robs them of their dignity. We define mental health and how mental problems are assessed and treated. We focus on several specific problems, including depression, delirium, dementia, anxiety disorders, psychotic disorders, and substance abuse. As we consider different types of mental dis- orders, we note how each is diagnosed, the known causes, and effective treatments that are available.
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276 CHAPTER 10
10.1 Mental Health and the Adult Life Course LEARNING OBJECTIVES
How are mental health and psychopathology defined?
What are the key dimensions used for categorizing psychopathology?
Why are ethnicity and aging important variables to consider in understanding mental health?
Janet lives alone in a small apartment . Lately, some of her neighbors have noticed she doesn’t come to church services as regularly as she used to. Betty, her friend and neighbor, noticed Janet cries a lot when she’s asked whether anything is wrong and at times seems confused. Betty knows several of Janet’s friends died recently but still wonders whether something more serious is wrong with her.
Situations like Janet’s are common. Like Betty, we might think Janet is trying to deal with the loss of friends and is simply experiencing grief, but there may be something more serious; could Janet’s confusion indicate a physical or mental health problem? Janet’s situation points out the difficulty in knowing exactly where good mental health ends and mental illness or mental disorder begins. What distinguishes the study of mental disorders, or psychopathology, in adulthood and aging is not so much the content of the behavior as its context, that is, whether it interferes with daily functioning. To understand psychopathology as mani- fested in adults of different ages, we must see how it fits into the life-span developmental perspective outlined in Chapter 1 .
Defining Mental Health and Psychopathology
The precise difference between mental health and mental disorder has never been clear (Segal, Qualls, & Smyer, 2011). Most scholars avoid the issue entirely or simply try to explain what mental health or psycho- pathology is not. How to tell the difference between normal or abnormal behavior is hard to define pre- cisely because expectations and standards for behav- ior change over time, situations, and across age groups (Zarit & Zarit, 2006). Researchers and practitioners refer to Birren and Renner’s (1980) classic argument
that mentally healthy people have the following char- acteristics: a positive attitude toward self, an accurate perception of reality, a mastery of the environment, autonomy, personality balance, and growth and self- actualization. Thus, all these characteristics must be evaluated when determining the mental health status of an individual.
One could argue to the extent these characteris- tics are absent, mental disorder or psychopathology becomes more likely. In that case, we would consider behaviors that are harmful to individuals or others, low- ers well-being, and perceived as distressing, disrupting, abnormal, or maladaptive. Although this approach is used frequently with younger or middle-aged adults, it presents problems when applied to older adults (Segal et al., 2011; Zarit & Zarit, 2006). Some behaviors con- sidered abnormal under this definition may actually be adaptive under some circumstances for many older people (such as isolation, passivity, or aggressiveness).
Consequently, an approach to defining abnormal behavior that emphasizes considering behaviors in isolation and from the perspective of younger or mid- dle-aged adults is inadequate for defining abnormal behaviors in older adults. Because of physical, finan- cial, social, health, or other reasons, older adults do not always have the opportunity to master their environ- ment. Depression or hostility may be an appropriate and justified response to such limitations. Moreover, such responses may help them deal with their situation more effectively and adaptively.
Statistics on the prevalence of various mental dis- orders as a function of age are difficult to obtain due to these definitional issues. Figure 10.1 compares com- mon forms of mental disorder as a function of age from one of the few good investigations of this issue (Kessler, Berglund, Demler, Jin, Merakangas, & Walters, 2005). Further analyses of data from national surveys reveals older European Americans and Caribbean Blacks have a higher lifetime prevalence of major depressive dis- order than do African Americans (Woodward, Taylor, Abelson, & Matusko, 2013).
The important point in differentiating mental health from psychopathology is that behaviors must be interpreted in context. We must consider what else is happening and how the behavior fits the situation in addition to such factors as age and other personal characteristics.
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 277
A Multidimensional Life-Span Approach to Psychopathology
Suppose two people, one young and one old, came into your clinic, each complaining about a lack of sleep, changes in appetite, a lack of energy, and feeling down. What would you say to them?
If you evaluate them in identical ways, you might be headed for trouble. As we saw in other chapters, older and younger adults may think or view themselves differently, so the meaning of their symptoms and com- plaints may also differ, even though they appear to be the same. This point is often overlooked (Segal et al., 2011). Some models of psychopathology assume the same underlying cause is responsible for maladaptive behavior regardless of age and symptoms of the mental disease are fairly constant across age. Although such models often are used in clinical diagnosis, they are inadequate for understanding psychopathology in old age. Viewing adults’ behavior from a life-span devel- opmental forces perspective makes a big difference in how we understand psychopathology. Let’s see why.
Biological Forces. Various neurological changes, chronic diseases, functional limitations, and other ail- ments can change behavior. Changes in the structure and functioning of the brain can have important effects on behavior ( Chapter 2 ). Because health problems increase with age (see Chapters 3 and 4 ) we must be more sensitive to them when dealing with older adults. In addition, genetic factors often underlie important problems in old age. Some forms of Alzheimer’s dis- ease have a clear genetic component.
Physical problems may provide clues about under- lying psychological difficulties; for example, marked changes in appetite may be a symptom of depression. Moreover, physical problems may present themselves as psychological ones. Extreme irritability can be caused by thyroid problems, and memory loss can result from certain vitamin deficiencies. In any case, physical health and genetic factors are important dimensions to take into account in diagnosing psy- chopathology in adults and should be among the first avenues explored.
Psychological Forces. Psychological forces across adulthood are key to understanding psychopathology. As we saw in Chapters 6 , 7 , 8 , and 9 , several important changes in memory, intelligence, social cognition, and personality must be considered carefully in interpret- ing behavior. Normative changes with age in these are- nas can mimic certain mental disorders; likewise, these changes make it more difficult to tell when an older adult has a given type of psychopathology.
In addition, the nature of a person’s relationships with other people, especially family members and friends, is a basic dimension in understanding how psychopathology is manifested in adults of different ages. Important developmental differences occur in the interpersonal realm; younger adults are more likely to be expanding their network of friends, whereas older adults are more likely to be experiencing losses. Chapter 11 summarizes developmental changes in key relationships that may influence adults’ interpretation of symptoms.
Figure 10.1 Lifetime prevalence of age-of-onset distribution of DSM-IV disorders in the National Comorbidity Survey Replication Source: Kessler, Ronald C., Berglund, Patricia, Demler, Olga, Jin, Robert, Merakangas, Kathleen, & Walters, Ellen. (2005). Arch Gen Psychiatry, 62 , 593–602. Copyright © 2005 by American Medical Association. All rights reserved.
0
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ce %
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Any anxiety disorder
Major depressive disorder
Alcohol abuse
30–44 years
60 years and up
18–29 years
Disorders
45–59 years
Alcohol dependence
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278 CHAPTER 10
Sociocultural Forces. The social norms and cultural factors we all experience also play a key role in help- ing define psychopathology. They influence people’s behaviors and affect our interpretation of them. An older woman who lives alone in a high-crime area may be highly suspicious of other people. To label her behavior “paranoid” may be inappropriate because her well-being may depend on maintaining a certain level of suspicion of others’ motives toward her. Because customs differ across cultures, behaviors that may be normative in one culture may be viewed as indicating problems in another. In short, we must ask whether the behavior we see is appropriate for a person in a par- ticular setting.
Life-Cycle Factors. How people behave at any point in adulthood is strongly affected by their past experi- ences and the issues they face. These life-cycle factors must be taken into account in evaluating adults’ behav- iors. A middle-aged woman who wants to go back to school may not have an adjustment disorder; she may simply want to develop a new aspect of herself. Some might interpret her behavior as an inability to cope with her current life situation when that is not the case at all; rather, she has a rational evaluation of her life and real- izes she needs a degree to advance in her profession.
Likewise, an older man who provides vague answers to personal questions may not be resistant; he may simply be reflecting his generation’s reluctance to disclose the inner self to a stranger. Most important, the meaning of particular symptoms change with age. Problems with early morning awakenings may indicate depression in a young adult but may simply be a result of normal aging in an older adult (see Chapter 3 ).
Ethnicity, Gender, Aging, and Mental Health In neither the general nor the ethnic populations do most people have mental disorders (Muntaner, Ng, Vanroelen, Christ, & Eaton, 2013; Segal et al., 2011). However, social disparities such as differential access to health care can result in apparently different preva- lence of mental disorders. Poverty and social class are primary influences (Muntaner et al., 2013).
Neither positive mental health nor psychopathol- ogy has been adequately defined in any group in a way that takes social context into account so as to be sensi- tive to contextual differences in ethnic communities.
For example, although many explanations of deviant and antisocial behavior are grounded in the oppressive life conditions that characterize many ethnic commu- nities, the conceptualization of positive mental health for older ethnic groups does not take into account the lifetime accumulation of such effects (Jackson, Anto- nucci, & Gibson, 1995; Morrell, Echt, & Caramagno, 2008) nor the effects of a lifetime of inadequate access to health care (Miranda, McGuire, Williams, & Wang, 2008). However, such sensitivity to conditions does not preclude finding commonalities across ethnic groups; indeed, identifying such commonalities would be an excellent place to start.
What little data we have suggest both similari- ties and differences in the incidence of specific types of psychopathology across different ethnic groups at a general level. However, there are some differences within subgroups of ethnic groups. As noted earlier, Caribbean blacks differ from African Americans in their prevalence of depression (Woodward et al., 2013).
People in different ethnic groups have different ways of describing how they feel, so they may describe symptoms of mental disorders differently. Such differ- ences are amplified by ethnic and cultural differences in what they are supposed to reveal to strangers about their inner self. Placed in a context of important dif- ferences in social stressors, physical health, and age, assessing mental health in older ethnic adults is a daunting task (Yancura & Aldwin, 2010).
What can be done to determine the ways ethnicity influences mental health? Jackson et al. (1995) were among the first to argue researchers should adopt an ethnic research matrix that takes as its defining ele- ments ethnicity, national origin, racial group mem- bership, gender, social and economic statuses, age, acculturation, coping reactions, and mental health outcomes (e.g., psychopathology, positive adjust- ment). Only by adopting this comprehensive approach can we understand what, how, and when aspects of race, ethnicity, age, and the life course influence men- tal health.
Gender differences in prevalence of various mental disorders are well known and documented (Rosenfield & Mouzon, 2013). A community study in Korea and a study of records in a day hospital in Italy found being female increased the risk of depressive symptoms (Luca, Prossimo, Messina, Luca, Romeo, & Calandra,
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 279
10.2 Developmental Issues in Assessment and Therapy LEARNING OBJECTIVES
What key areas are included in a multidimensional approach to assessment?
What factors influence the assessment of adults? How are mental health issues assessed? What are some major considerations for therapy
across adulthood?
Juan is a 76 -year-old World War II veteran living in California. Over the past year, his wife, Rocio, noticed Juan’s memory isn’t quite as sharp as it used to be; Juan also has less energy, stays home more, and does not show as much interest in playing dominos, a game at which he excels. Rocio wonders what might be wrong with Juan.
Many adults can relate to Rocio because they are concerned about someone they know. Whether the person is 25 or 85 , it is important to be able to deter- mine whether memory problems, energy loss, social withdrawal, or other areas of concern really indicate an underlying problem. As you might suspect, health care professionals should not use identical approaches to assess and treat adults of widely different ages. In this section, we consider how assessment methods and therapies must take developmental differences into account.
2013; Oh, Kim, Lee, Seo, Choi, & Nam, 2013). Males who are depressed are more likely to commit suicide than are women (Hawton, Casañas i Comabella, Haw, & Saunders, 2013).
Just as in the case of ethnicity, though, biases regarding gender and symptom interpretation may influence reported prevalence rates (Rosenfield & Mouzon, 2013). Thus, interpreting data regarding how many people of a specific background have a men- tal disorder must be done quite carefully, taking into account all of the aspects of the biopsychosocial model.
Areas of Multidimensional Assessment What does it mean to assess someone? Assessment makes it possible to describe the behavior or other characteristics of people in meaningful ways (Gould, Edelstein, & Gerolimatos, 2012; Stoner, O’Riley, & Edelstein, 2010). Assessment is a formal process of measuring, understanding, and predicting behavior. It involves gathering medical, psychological, and socio- cultural information about people through various means, such as interviews, observation, tests, and clini- cal examinations.
As noted in Chapter 1 , two central aspects of any assessment approach are reliability and validity. With- out these psychometric properties, we cannot rely on the assessment method to provide good information. In addition, any assessment method must be of practi- cal use in determining the nature of the problem and choosing the appropriate treatment.
A multidimensional assessment approach is most effective (Gould et al., 2012; Stoner et al., 2010). Mul- tidimensional assessment is often done by a team of professionals; a physician may examine the medication regimen; a psychologist, the cognitive functioning; a nurse, the daily living skills; and a social worker, the economic and environmental resources. Let’s consider Juan’s situation as an example.
A thorough assessment of Juan’s physical health is essential, as it is for adults of all ages, especially for older adults. Many physical conditions can create (or hide) mental health problems, so it is important to identify any underlying issues. Laboratory tests can also be ordered provide additional clues to the pres- ence or even the cause of the problem.
Establishing Juan’s cognitive ability is also key. Complaints of cognitive problems increase across adulthood, so it is important to determine the extent abnormal changes in older people discriminate from normative change. Adults of all ages can be given intel- ligence tests, neuropsychological examinations, and mental status examinations. Mental status exams are especially useful as quick screening measures of mental competence used to screen for cognitive impairment; one commonly used instrument, the Mini Mental Status Exam (MMSE), is shown in Table 10.1 . If Juan’s score on these brief measures indicated potential problems, more complete follow-up assessments would be used.
Adult Development in Action As an elected official, how would you put the data about mental health and aging into social policy?
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280 CHAPTER 10
It is important to remember that scales such as the MMSE are only used for general screening and not for final diagnosis.
Psychological functioning is typically assessed through interviews, observation, and tests or question- naires. Usually a clinician begins with an interview of Juan and brief screening instruments and follows up, if necessary, with more thorough personality invento- ries, tests, or more detailed interviews.
How well Juan functions in his daily life is also assessed carefully. Usually this entails determining whether he has difficulty with activities of daily living and instrumental activities of daily living (see Chap- ter 4 ). Also assessed is the person’s decision-making capacity; each state has legal standards guiding the competency assessment.
In general, it is important to assess the broad array of support resources available to older adults (Randall, Martin, Bishop, Johnson, & Poon, 2012). This includes social networks as well as other community resources.
Factors Influencing Assessment Health care professionals’ preconceived ideas about the people they assess may have negative effects on the assessment process (Gould et al., 2012; Stoner et al., 2010). Two areas of concern are biases (negative or positive) and environmental conditions (where the assessment occurs, sensory or mobility problems, and health of the client).
Many types of bias have been documented as affecting the assessment process (Gould et al., 2012; Stoner et al., 2010). Negative biases about people are widespread and include racial, ethnic, and age ste- reotypes. Clinicians may hold negative biases against younger adults of ethnic minorities and more readily “diagnose” problems that do not truly exist. Likewise, because of ageism, older adults may be “diagnosed” with untreatable problems such as Alzheimer’s disease rather than treatable problems such as depression (see Chapter 1 ). In contrast, positive biases about certain people also work against accurate assessment. A belief that women do not abuse alcohol may result in a mis- diagnosis; beliefs older adults are “cute” may mitigate against accurate assessment of abilities. Clearly, the best defense against bias is for clinicians to be fully educated about their prospective clients.
The environmental conditions where the assess- ment occurs can also work against accurate outcomes. Clinicians do not always have the option of selecting an ideal environment; rather, assessments sometimes occur in hallways, with a bedridden patient, or in a noisy emergency room. People with sensory or motor difficulties must be accommodated with alternative assessment formats. The patient’s physical health may
Source: Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549, from the Mini Mental Status Examination, by Marshal Folstein and Susan Folstein. Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc., by calling (813) 968–3003.
Cognitive Area Activity
Orientation to time “What is the date?”
Registration stop “Listen carefully. I am going to say three words. You say them back after I say them. Ready? Here they are … APPLE [pause], PENNY [pause], TABLE [pause]. Now repeat those words back to me.” [Repeat up to 5 times, but score only the first trial.]
Naming “What is this?” [Point to a pencil or pen.]
Reading stimulus form
“Please read this and do what it says.” [Show examinee the words on the form.]
CLOSE YOUR EYES
Table 10.1
A Sampling of Questions from the Mini Mental Status Exam
D an
n Ta
rd if/
LW A
/C or
bi s
A thorhorougouggh ah ah assessssessmsmenent offof phpphp ysical health h iis as n essesential part of a comompompmprehrehensensiveiveee asassessessmesm nt for dededeppreprepressiss on oor anyy mental health prprrp obobloblem..
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 281
also complicate assessment; in many cases with older adults, health issues can also create a negative bias so mental health issues may be overlooked when a health problem is discovered (Karel, Gatz, & Smyer, 2012; Qualls & Benight, 2007).
Taken together, clinical assessment is an excel- lent example of how the forces of development come together. Only when all four forces are considered can mental health problems be assessed accurately.
Assessment Methods How are adults assessed? In terms of cognitive, psycho- logical, and social assessments, there are six primary methods (Edelstein & Kalish, 1999): interview, self- report, report by others, psychophysiological assess- ment, direct observation, and performance-based assessment.
Clinical interviews are the most widely used assess- ment method (Gould et al., 2012; Stoner et al., 2010). They are useful because they provide both direct infor- mation in response to the questions and nonverbal information such as emotions. Interviews can be used to obtain historical information, determine appropri- ate follow-up procedures, build rapport with the client, obtain the client’s informed consent to participate in the assessment, and evaluate the effects of treatment. All these tasks are important with adults of all ages. When interviewing older adults, though, it may be necessary to use somewhat shorter sessions, and be aware of sensory deficits and cognitive and medical conditions that may interfere with the interview.
Many commonly used assessment measures are presented in a self-report format. As noted in Chapter 1 , a major concern is the reliability and validity of these measures with older adults.
Family members and friends are an important source of information. In some cases, such as Alzheim- er’s disease, discrepancies between the client’s and others’ description of the problem can be diagnostic. Such sources also are valuable if the client is unlikely or unable to tell the whole story. Such information can be obtained through interviews or self-report.
Psychophysiological assessment examines the relation between physical and psychological func- tioning. One common psychophysiological measure is the electroencephalogram (EEG), which measures brain wave activity. Other measures include heart rate,
muscle activity, and skin temperature. Such measures provide a way to measure the body’s reaction to certain stimuli, especially when the client gets anxious or fear- ful in response to them.
In some cases it is possible to observe the cli- ent through systematic or naturalistic observation (see Chapter 1 ). Direct observation is especially use- ful when the problem involves specific behaviors, as in eating disorders. A variety of techniques exist for structuring observations, and they can be used in a wide array of settings, from homes to nursing homes.
Finally, performance-based assessment involves giving clients a specific task to perform. This approach underlies much cognitive and neuropsychological assessment. A person’s memory is assessed by giving him or her a list of items to remember and then test- ing retention. Some neuropsychological tests involve drawing or copying pictures.
Developmental Issues in Therapy Assuming Juan is assessed properly and found to have a mental disorder, what next? How can he be helped? Therapy for mental disorders generally involves two approaches (Segal et al., 2011): medical treatment and psychotherapy. Medical treatment most often involves the use of various medications based on the underlying physiological causes of the disorders. Psychotherapy usually involves talking to a clinician or participating in a group. In either case, it is essential to take into account developmental differences in people as they age.
As we saw in Chapter 3 , the ways medications work change with age. The effective dosage of a spe- cific medication may be different for younger, middle- aged, and older adults. In some cases, medications that work in one age group do not work for others.
In terms of psychotherapy, clinicians must adapt techniques to the unique needs of older adults (Zarit & Zarit, 2006). This has led some to propose a new, positive approach to geriatric psychiatry and gero- psychology be adopted (Jeste & Palmer, 2013). This positive approach focuses “on recovery, promotion of successful ageing, neuroplasticity, prevention, and interventions to enhance positive psychologi- cal traits such as resilience, social engagement and wisdom” (p. 81 ).
Another major issue in psychotherapy is estab- lishing whether a particular therapeutic approach
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282 CHAPTER 10
10.3 The Big Three: Depression, Delirium, and Dementia LEARNING OBJECTIVES
What are the most common characteristics of people with depression? How is depression diagnosed? What causes depression? What is the relation between suicide and age? How is depression treated?
What is delirium? How is it assessed and treated? What is dementia? What are the major symptoms
of Alzheimer’s disease? How is it diagnosed? What causes it? What intervention options are there? What are some other major forms of dementia? What do family members caring for patients with dementia experience?
Ling has lived in the same neighborhood in New York for all of her 74 years. Her son, who visits her every week, started noticing Ling’s memory problems have got- ten much worse, her freezer is empty and her refrigera- tor has lots of moldy food. When he investigated further, he found her bank accounts were in disarray. Ling’s son wonders what could be wrong with her.
Ling’s behaviors certainly do not appear to be typical of older adults. Unfortunately, Ling is not alone in experiencing difficulties; many older adults have
is effective, based on research and clinical evidence. Major professional associations provide guidelines in their respective fields; the American Medical Associa- tion provides evidence-based approaches to medical therapy (American Medical Association, 2009), and the American Psychological Association developed a set of criteria for evidence-based psychotherapy (American Psychological Association, 2005). The ther- apeutic approaches that meet the standard for adult therapy appear to be effective for a wide range of ages and are generally the therapies of choice. As we con- sider specific disorders, we focus on evidence-based approaches to therapy.
similar problems. In this section, we consider three of the most common difficulties: depression, delirium, and dementia. As we will see, both depression and delir- ium are treatable; the most common form of dementia, Alzheimer’s disease, is not. The three conditions are connected by overlapping symptoms and the possibility that they may coexist. Let’s consider each in detail.
Depression Most people feel down or sad from time to time, per- haps in reaction to a problem at work or in one’s rela- tionships. But does this mean that most people are depressed? How is depression diagnosed? Are there age-related differences in the symptoms examined in diagnosis? How is depression treated?
First of all, let’s dispense with a myth. Contrary to the popular belief most older adults are depressed, the rate of severe depression declines from young adulthood to old age for healthy people as shown in Figure 10.2 (National Institute of Mental Health, 2013). However,
Adult Development in Action What factors must be considered in conducting a thorough clinical assessment for mental disorders?
12-month Prevalence of Depression Among All U.S. Adults by Age
0
* Data not available for 2005 Data courtesty of SAMHSA
18–25 26–49* 50+
2
4
6
10
8
12
14
16
Pe rc
en t
18
20 2005 2006
2007 2008
Figure 10.2 12 - month prevalence of depression among all U.S. residents by age. Source: National Institute of Mental Health (2013). Major depressive disorder among adults . Retrieved from http://www.nimh.nih.gov/statistics/1MDD_ ADULT.shtml .
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 283
this downward age trend does not hold in all cultures; depressive symptoms among Chinese older adults rose over a 24 -year period (1987–2010, inclusive) (Shao, Li, Zhang, Zhang, Zhang, & Qi, 2013).
In the United States, the average age at diagnosis for depression is 32 (National Institute of Mental Health, 2013). Being female, unmarried, widowed, or recently bereaved; experiencing stressful life events; and lacking an adequate social support network are more common among older adults with depression than younger adults (Segal et al., 2010). Less than 5 % of older adults living in the community show signs of depression, but the percentage rises to over 13 % among those who require home health care (National Institute of Mental Health, 2008). Subgroups of older adults who are at greater risk include those with chronic illnesses (of whom up to half may have major depression), nursing home residents, and family care providers (who commonly report feel- ing depressed; DeFries & Andresen, 2010).
Rates of clinical depression vary across ethnic groups, although correct diagnosis is frequently a problem with minorities due to inadequate access to physical and mental health care (Alegría et al., 2008). These issues also apply to immigrants (Ladin & Reinhold, 2013), who have higher rates of depres- sion, and to treatment disparities relating to minorities (Zurlo & Beach, 2013). Rates for depression tend to be higher in Latino older adults than for other groups of older adults (National Institute of Mental Health, 2012). Latinos who speak primarily Spanish or are foreign-born are especially likely to show depression (Mercado-Crespo et al., 2008). Older African Ameri- cans have lower rates of depression than European Americans (NIMH, 2013). Clearly, the pattern of eth- nic differences indicates the reasons for them are com- plex and not well understood.
Finally, depression commonly accompanies other chronic conditions. Some common chronic conditions such as coronary heart disease (Tully & Cosh, 2013), diabetes (Kaur, Kumar, & Navis, 2013), and asthma and arthritis (Peltzer & Phaswana-Mafuya, 2013). For those people who do experience depression, let’s exam- ine its diagnosis and treatment.
General Symptoms and Characteristics of People with Depression. The most prominent feature of clini- cal depression is dysphoria , that is, feeling down or blue.
There are important developmental differences in how dysphoria is expressed (Segal et al., 2010). Older adults may not talk about their feelings at all, have feel- ings that flow from life events such as bereavement that mimic depression, or label their down feelings as depression but rather as pessimism or helpless- ness (NIHSeniorHealth, 2011; Zarit & Zarit, 2006). In addition, older adults are more likely to show signs of apathy, subdued self-deprecation, expressionlessness, and changes in arousal than are younger people (Segal et al., 2010). It is common for depressed older adults to withdraw, not speak to anyone, confine themselves to bed, and not take care of bodily functions. Younger adults may engage in some of these behaviors but do so to a much lesser extent. Thoughts about suicide are common, and may reflect a shutdown of a person’s basic survival instinct.
The second major component of clinical depres- sion is the accompanying physical symptoms (NIHSeniorHealth, 2011). These include insomnia, changes in appetite, diffuse pain, troubled breathing, headaches, fatigue, and sensory loss. The presence of these physical symptoms in older adults must be evalu- ated carefully, though. As noted in Chapter 3 , some sleep disturbances may reflect normative changes unre- lated to depression; however, certain types of sleep dis- turbance, such as regular early morning awakening, are related to depression, even in older adults (Wiebe, Cas- soff, & Gruber, 2012). There is evidence that changes in the prefrontal cortex may be responsible for the link between sleep disturbance and depression; given that such changes occur with age, it may be one reason for the difficulty in understanding whether sleep distur- bances are related to clinical depression in older adults.
Alternatively, physical symptoms may reflect an underlying physical disease that is manifested as depression. Indeed, many older adults admitted to the hospital with depressive symptoms turn out to have previously undiagnosed medical problems that are uncovered only after thorough examinations and evaluations (Mulley, 2008). These underlying health problems that appear as depression include vitamin deficiencies (e.g., B12), thyroid disease, certain viruses, and medication interactions and side effects (NIHSe- niorHealth, 2011).
The third primary diagnostic characteristic is the symptoms must last at least 2 weeks. This criterion is
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284 CHAPTER 10
used to rule out the transient symptoms common to all adults, especially after a negative experience such as receiving a rejection letter from a potential employer or getting a speeding ticket.
Fourth, other causes for the observed symptoms must be ruled out (Mulley, 2008). Other health prob- lems, neurological disorders, medications, metabolic conditions, alcoholism, or other forms of psychopa- thology can cause depressive symptoms. These causes influence appropriate treatment decisions.
Finally, the clinician must determine how patients’ symptoms affecting their daily life. Can they carry out responsibilities at home? How well do they inter- act with other people? What about effects on work or school? Clinical depression involves significant impairment in daily living.
Assessment Scales. Numerous scales are used to assess depression, but because most were developed on younger and middle-aged adults, they are most appro- priate for these age groups. The most important dif- ficulty in using these scales with older adults is they all include several items assessing physical symptoms. The Beck Depression Inventory (Beck, 1967) contains items that focus on feelings and physical symptoms. Although the presence of such symptoms usually is indicative of depression in younger adults, as we noted earlier, such symptoms may not be related to depres- sion at all in older adults.
Scales such as the Geriatric Depression Scale (Yesavage et al., 1983) aimed specifically at older adults have been developed. Physical symptoms are omitted, and the response format is easier for older adults to follow. This approach reduces the age-related symp- tom bias and scale response problems with other self- report scales measuring depressive symptoms. A third screening inventory, the Center for Epidemiologic Studies-Depression Scale (CES-D; Radloff, 1977) is also frequently used in research.
An important point to keep in mind about these scales is that the diagnosis of depression should never be made on the basis of a single scale. As we have seen, the symptoms observed in clinical depression could be indicative of other problems, and symptom patterns are complex. Only by assessing many aspects of physi- cal and psychological functioning can a clinician make an accurate assessment.
Causes of Depression. Several biological and psy- chosocial theories about the causes of depression have been proposed (Segal et al., 2010). Biological theories focus most on genetic predisposition, brain changes, and changes in neurotransmitters (McKinney & Sibille, 2013). The genetic evidence is based two sets of data: (a) on several studies that show higher rates of depression in relatives of depressed people than would be expected given base rates in the population; and (b) genetically-driven age-related changes in brain structures. The first type of genetic link is stronger in early-onset depression than in late-onset depression, whereas the second type of evidence is thought to underlie much of late-life onset.
There is substantial research evidence that severe depression is linked to imbalance in neurotransmitters such as low levels of serotonin and the action of brain- derived neurotrophic factor (Hashimoto, 2013). Low levels of serotonin are a likely result from high levels of stress experienced over a long period. The usual signs of low serotonin levels include waking up in the early morning (often around 4 : 00 a.m. ), difficulty in con- centrating and paying attention, feeling tired and list- less, losing interest in activities such as sex or visiting friends, and racing of the mind with strong feelings of guilt and of reliving bad past experiences and creating negative thoughts. These effects of low serotonin are similar to those that characterize depression, which is why researchers believe that one possible cause is low serotonin.
Brain-derived neurotrophic factor (BDNF) is a compound found in blood serum, and its level is nega- tively correlated with the severity of depression (i.e., lower levels of BDNF are correlated with higher levels of depression). Research shows the use of antidepres- sant medication raises the level of BDNF.
Low levels of another neurotransmitter, norepi- nephrine, that regulates arousal and alertness, may be responsible for the feelings of fatigue associated with depression. These neurochemical links are the basis for the medications developed to treat depression we will consider a bit later.
The psychological effects of loss is the most com- mon basis for psychosocial theories of depression (Segal et al., 2010). Bereavement or other ways of los- ing a relationship is the type of loss that has received the most attention, but the loss of anything considered
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 285
potentially serious side effects (for a summary, see the Mayo Clinic’s website on side effects of antide- pressant medications where you can find up-to-date information).
The most common first-line medication used to treat depression is selective serotonin reuptake inhibi- tors (SSRIs; Jainer et al., 2013). SSRIs have the low- est overall rate of side effects of all antidepressants, although some side effects can be serious in some patients. SSRIs work by boosting the level of serotonin, a neurotransmitter involved in regulating moods that was discussed earlier.
Other types of first-line medications are serotonin and norepinephrine reuptake inhibitors (SNRIs), norepinephrine and dopamine reuptake inhibitors (NDRIs), combined reuptake inhibitors and receptor blockers, and tetracyclic antidepressants.
If the first-line medications do not work, the next most popular medications are the tricyclic antide- pressants. These medications are most effective with younger and middle-aged people; in those age groups they work about 70 % of the time. The main problem
personally important could also be a trigger. More- over, these losses may be real and irrevocable, threat- ened and potential, or imaginary and fantasized. The likelihood these losses will occur varies with age. Middle-aged adults are more likely to experience the loss of physical attractiveness, for example, whereas older adults are more likely to experience the loss of a loved one.
Cognitive-behavioral theories of depression adopt a different approach that emphasizes internal belief systems and focus on how people interpret uncontrol- lable events (Beck, 1967). The idea underlying this approach is experiencing unpredictable and uncon- trollable events instills a feeling of helplessness result- ing in depression. In addition, perceiving the cause of negative events as some inherent aspect of the self that is permanent and pervasive also plays an important role in causing feelings of helplessness and hopeless- ness, as well as feelings of personal responsibility for the “fact” their life is in shambles. Importantly, people tend to ruminate on these negative ideas, often losing sleep doing so. Baddeley (2013) argues such negative self-thoughts and rumination are due to an inappro- priate setting of the pleasurable experience detector in the brain, thus linking cognitive-behavior theory with biological theories of depression.
Treatment of Depression. As we have seen, depres- sion is a complex problem that can result from a wide variety of causes. However, an extremely crucial point is most forms of depression benefit from interven- tion (Segal et al., 2010). Treatment of depression falls roughly into two categories: medical treatments and psychotherapy.
Medical treatments are typically used in cases of severe depression and involve mainly medication, but in some cases of long-term severe depression, these treatments include electroconvulsive therapy. For less severe forms of depression, and usually in conjunction with medication for severe depression, there are vari- ous forms of psychotherapy. A summary of the various treatment options is presented in Table 10.2 .
Three families of medications are used to com- bat severe depression. Increasingly, these medications target specific neurotransmitter receptors rather than work by general action in the brain (Jainer, Kamat- chi, Marzanski, and Somashekar, 2013). Each has
Source : Sunderland, T., Lawlor, B. A., Molchan, S. E., & Martinez, R. A. (1988). Depressive syndromes in the elderly: Special concerns. Psychopharmacology Bulletin, 24 , 567–576.
Table 10.2
Physical Illness That Causes Depression in Older Adults Coronary artery disease Hypertension, myocardial infarction, coronary artery
bypass surgery, congestive heart failure
Neurological disorders Cerebrovascular accidents, Alzheimer’s disease,
Parkinson’s disease, amyotrophic lateral sclerosis, multiple sclerosis, Binswanger’s disease
Metabolic disturbances Diabetes mellitus, hypothyroidism or
hyperthyroidism, hypercortisolism, hyperparathyroidism, Addison’s disease, autoimmune thyroiditis
Cancer Pancreatic, breast, lung, colonic, and ovarian
carcinoma; lymphoma; and undetected cerebral metastasis
Other conditions Chronic obstructive pulmonary disease, rheumatoid
arthritis, deafness, chronic pain, sexual dysfunction, renal dialysis, chronic constipation
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286 CHAPTER 10
with tricyclic antidepressants in older adults is that they are more likely to have other medical conditions or to be taking other medications that preclude their use. People who are taking antihypertensive medica- tions or who have any of a number of metabolic prob- lems should not take the tricyclic antidepressants. Moreover, the risk of side effects beyond dry mouth, some of which can be severe, is much greater in older adults, although some of the newer tricyclics have sig- nificantly lower risk.
If none of these medications are effective, a third group of drugs that relieve depression is the mono- amine oxidase (MAO) inhibitors, so named because they inhibit MAO, a substance that interferes with the transmission of signals between neurons. MAO inhibitors generally are less effective than the tricy- clics and can produce deadly side effects. Specifi- cally, they interact with foods that contain tyramine or dopamine—mainly cheddar cheese but also oth- ers, such as wine and chicken liver—to create dan- gerously and sometimes fatally high blood pressure. MAO inhibitors are used with extreme caution, usually only after SSRIs and HCAs have proved ineffective.
If periods of depression alternate with periods of mania or extremely high levels of activity, a diagno- sis of bipolar disorder is made (American Psychiatric Association, 1994). Bipolar disorder is character- ized by unpredictable, often explosive mood swings as the person cycles between extreme depression and extreme activity. The drug therapy of choice for bipolar disorder is lithium (Malhi, Tanious, Das, Coulston, & Berk, 2013). Lithium is effective in con- trolling the mood swings, although researchers do not completely understand why it works. The use of lithium must be monitored closely because the dif- ference between an effective dosage and a toxic dos- age is small. Because lithium is a salt, it raises blood pressure, making it dangerous for people who have hypertension or kidney disease. The effective dosage for lithium decreases with age; physicians unaware of this change run the risk of inducing an overdose, especially in older adults. Compliance is also a prob- lem, because no improvement is seen for 4 to 10 days after the initial dose and because many people with bipolar disorder do not like having their moods con- trolled by medication.
Electroconvulsive therapy (ECT) is an effective treatment for severe depression, especially in people whose depression has lasted a long time, who are sui- cidal, who have serious physical problems caused by their depression, and who do not respond to medi- cations (National Institute of Mental Health, 2011). Unlike antidepressant medications, ECT has immedi- ate effects. Usually only a few treatments are needed, in contrast to long-term maintenance schedules for drugs. But ECT may have some side effects that affect cognitive functioning (Gardner & O’Connor, 2008). Memory of the ECT treatment itself is lost. Memory of other recent events is temporarily disrupted, but it usually returns within a week or two.
In addition to ECT, there are other brain stimu- lation therapies for severe depression. These newer approaches include vagus nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS). Although these methods are not yet com- monly used, research has suggested they show promise.
Psychotherapy is a treatment approach based on the idea that talking to a therapist about one’s prob- lems can help. Often psychotherapy can be effective by itself in treating depression. In cases of severe depres- sion, psychotherapy may be combined with drug therapy or ECT. Two general approaches seem to work best for depression: behavior therapy , which focuses on attempts to alter current behavior without necessarily addressing underlying causes, and cognitive behavior therapy , which attempts to alter the ways people think.
The fundamental idea in behavior therapy is that depressed people receive too few rewards or rein- forcements from their environment (Lewinsohn, 1975). Thus the goal of behavior therapy is to get them to increase the good things that happen to them. Often this can be accomplished by having people increase their activities; if they do more, the likelihood is more good things will happen. In addi- tion, behavior therapy seeks to get people to decrease the number of negative thoughts they have because depressed people tend to look at the world pessimis- tically. They get little pleasure out of activities that nondepressed people enjoy a great deal: seeing a funny movie, playing a friendly game of volleyball, or being with a lover.
To get activity levels up and negative thoughts down, behavior therapists usually assign tasks that
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 287
force clients to practice the principles they are learning during the therapy sessions. This may involve going out more to meet people, joining new clubs, or just learn- ing how to enjoy life. Family members are instructed to ignore negative statements made by the depressed per- son and to reward positive self-statements with atten- tion, praise, or even money.
Cognitive behavior therapy for depression is based on the idea that depression results from maladaptive beliefs or cognitions about oneself. From this perspec- tive, a depressed person views the self as inadequate and unworthy, the world as insensitive and ungratifying, and the future as bleak and unpromising (Beck et al., 1979). In cognitive behavior therapy the person is taught how to recognize the thoughts that become so automatic and ingrained that other perspectives are not seen. Once this awareness has been achieved, the person learns how to evaluate the self, world, and future more realistically. These goals may be accomplished through homework assignments similar to those used in behavior therapy. These often involve reattributing the causes of events, examining the evidence before drawing conclusions, listing the pros and cons of maintaining an idea, and examining the consequences of that idea. Finally, peo- ple are taught to change the basic beliefs responsible for their negative thoughts. People who believe they have been failures all their lives or they are unlovable are taught how to use their newfound knowledge to achieve more realistic appraisals of themselves.
Cognitive behavior therapy is especially effective for older adults (Jeste & Palmer, 2013). This is good news, because medications may not be as effective or as tolerated by older adults because of age-related changes in metabolism.
Delirium Delirium is characterized by a disturbance of conscious- ness and a change in cognition that develop over a short period of time (American Psychiatric Association, 1994). The changes in cognition can include difficul- ties with attention, memory, orientation, and language. Delirium can also affect perception, the sleep–wake cycle, personality, and mood. Although the onset of delirium usually is rapid, its course can vary a great deal over the course of a day, with cognitive symptoms in older adults generally more severe than in younger or middle-aged adults (Leentjens et al., 2008).
Delirium can be caused by any of a number of medical conditions (such as stroke, cardiovascular disease, and metabolic condition), medication side effects, substance intoxication or withdrawal, exposure to toxins, or any combination of factors (Leentjens et al., 2008; Segal et al., 2010). Because they take more medications on average than other age groups, older adults are particularly susceptible to delirium. How- ever, delirium is often undiagnosed or misdiagnosed and symptoms are ascribed to other causes (Anand & MacLullich, 2013).
Assessment and treatment of delirium focus on the physiological causes. In general, the most impor- tant aspect of diagnosis is differentiating delirium from depression and dementia. The key features of each are shown in Table 10.3 . The severity of delirium is related to the level of the underlying physiological problem. In many cases, delirium is accompanied by severe misin- terpretations of the environment and confusion that is best alleviated by having one reliable family member or friend provide reassurance to the patient (Anand & MacLullich, 2013; Leentjens et al., 2008).
About one-third of cases of delirium are prevent- able (Anand & MacLullich, 2013). If the cause of non- preventable delirium can be identified and addressed, most cases of delirium can be cured. In some cases, however, delirium can be fatal or result in permanent brain damage (Leentjens et al., 2008).
Dementia Probably no other condition associated with aging is more feared than the family of disorders known as dementia. In dementia individuals can literally lose their mind, being reduced from a complex, thinking, feeling human being to a confused, vegetative victim unable even to recognize one’s spouse and children. Dementias serious enough to impair independent functioning affect nearly 37 million people globally, but predictions of how those numbers will change over the next few decades are mixed ( Christensen, Thinggaard, Oksuzyan, Steenstrup, Andersen- Ranberg, Jeune et al., in press; Matthews, Arthur, Barnes, Bond, Jagger, & Brayne, in press; Prince, Bryce, Albanese, Wimo, Ribeiro, & Ferri, 2013). Some research (e.g., Christensen et al., in press; Matthews et al., in press) predicts declin- ing rates of dementia as a result of healthier adults in more recent birth cohorts reaching old age, whereas
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288 CHAPTER 10
other research (e.g., Prince et al., 2013) predicts increased rates. Part of the difference in predictions could be because of the specific criteria used to mea- sure cognitive impairment, and part of it may be the composition of the samples. More work is needed to sort through these differing predictions.
Despite the different predictions about the future rate of dementia, it is the case that most older adults are not demented. For many people, the fear of demen- tia is the most serious problem, leading them to con- sider every lapse of memory a symptom. It is hard to know how many older adults have unstated fears about no longer being able to remember things in the same ways they did when they were younger; but as noted in Chapter 6 , memory abilities show some normative changes with age. Consequently, what many people
believe are signs they are becoming demented are actu- ally quite normal.
The Family of Dementias. Dementia is not a specific disease but rather a family of diseases characterized by cognitive and behavioral deficits involving some form of permanent damage to the brain. About a dozen forms of dementia have been identified. Dementia involves severe cognitive and behavioral decline and is not caused by a rapid onset of a toxic substance or by infec- tion (Prince et al., 2013). For example, if delirium is present, dementia cannot be diagnosed.
We focus on several types of dementias that are irreversible and degenerative. The most common and widely known of these is Alzheimer’s disease, but others are important as well: vascular dementia, Parkinson’s
Source : U.S. Public Health Service (1993).
Table 10.3
Summary of Depression Treatment Options
Antidepressant medications
Several options, including selective serotonin uptake inhibitors (SSRIs), tricyclics, MAO inhibitors, and others that have been shown to be effective in clinical trials research.
Adequate dosages, plasma levels, and treatment duration are essential to minimize response. Response may take 6 – 12 weeks, somewhat longer than in younger patients. Side effects may limit use.
Augmentation of antidepressants with lithium, thyroid medications, carbamazepine
Patients nonresponsive to several weeks of treatment with standard antidepressant medications may respond rapidly after these medications are added. Evidence is based on case series and reports.
May be useful in patients who are not responding or only partially responding to standard antidepressant medications. Constitutes acceptable clinical practice.
Electroconvulsive therapy Clearly effective in severe depression, depression with melancholia, and depression with delusions, and when antidepressants are not fully effective. Sometimes combined with antidepressants.
In medication-resistant patients, acute response rate is approximately 50 %. Relapse rate is high, necessitating attention to maintenance antidepressant treatment. Effects are more favorable with increasing age.
Psychotherapy More effective treatment than waiting list, no treatment, or placebo; equivalent to antidepressant medications in geriatric outpatient populations generally, with major or minor depression. About half of studies are group interventions. Therapy orientations were cognitive, interpersonal, reminiscence, psychodynamic, and eclectic.
Studies have been in older outpatients who were not significantly suicidal and for whom hospitalization was not indicated. There is no evidence of efficacy in severe depression. Distribution of responses may be different from the response to medication.
Combined antidepressant medication and psychotherapy
Effective in outpatients using manual-based therapies; the relative contributions of each component are not well understood.
Combined therapy has not been adequately studied in older adults.
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 289
disease, Huntington’s disease, alcoholic dementia, and AIDS dementia complex.
Alzheimer’s Disease. Alzheimer’s disease is the most common form of progressive, degenerative, and fatal dementia, accounting for perhaps as many as 70 % of all cases of dementia (National Institute on Aging, 2013a). New knowledge about Alzheimer’s disease is discovered all the time, so it is important to monitor the research literature. However, because it is such a terrible disease, news of potential breakthroughs too often do not pan out.
Alzheimer’s disease has several characteristics we will consider, both in terms of specific changes in the brain and behavioral symptoms.
Neurological Changes in Alzheimer’s Disease. The changes in the brain that characterize Alzheimer’s dis- ease are microscopic. Although great progress has
been made in diagnosing the disease, it is still the case definitive diagnosis of the disease can be done only at autopsy (National Institute on Aging, 2013b). These progressive changes eventually cause so much brain destruction the person dies. The microscopic changes that define Alzheimer’s disease are rapid cell death, neurofibrillary tangles, and neuritic plaques. Several changes in neurotransmitter levels also are observed. Rapid cell death occurs most in the hippocampus (a structure in the brain most closely involved in mem- ory), the cortex (the outer layer of the brain where our higher-level cognitive abilities reside), and the basal fore- brain (the lower portion of the front of the brain). This cell death occurs at a rate much greater than normal.
Neurofibrillary tangles (see Chapter 2 ) are accumu- lations of pairs of filaments in the neuron that become wrapped around each other; when examined under a microscope, these paired filaments look like intertwined spirals. Neurofibrillary tangles occur in several areas of the brain, and the number of tangles is directly related to the severity of symptoms, specifically the severity of memory impairment (Scuderi & Steardo, 2013).
Neuritic or amyloid plaques (see Chapter3) are spherical structures consisting of a core of beta-amyloid , a protein, surrounded by degenerated fragments of dying or dead neurons. The plaques are found in various parts of the brain, with the amount of beta-amyloid moderately related to the severity of the disease (Krut, Zetterberg, Blennow, Cinque, Hagberg, & Price, 2013). Degeneration of neurons in some areas of the brain results in the formation of vacuoles, or spaces that become filled with fluid and granular material.
Considerable recent research has focused on beta-amyloid as a major factor in Alzheimer’s disease, both in terms of the cause and possible avenues for treatment. The role of beta-amyloid is controversial, though. Some researchers view concentration of beta- amyloid as a biomarker of Alzheimer’s disease (Jack, Knopman, Jagust, Petersen, Weiner, Aisen et al., 2013; Krut et al., 2013). Others consider it an early warning of potential cognitive decline, even in the absence of any behavioral symptoms (Gandy & DeKosky, 2013). We will consider the controversy surrounding diagnos- tic categories related to Alzheimer’s disease a bit later.
Another protein involved in Alzheimer’s disease that has been the focus of much research is tau protein (Gandy & DeKosky, 2013; Krut et al., 2013). Unlike Ang
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290 CHAPTER 10
beta-amyloid protein, tau protein acts within a neuron (see Figure 10.3 ). Tau protein spreads across neurons and may provide a key to understanding how neurons die (Liu, Drouet, Wu, Witter, Small, Clelland et al., 2012). More research needs to be done to fully under- stand the role of tau protein in Alzheimer’s disease, but this is a promising avenue.
Although the structural changes occurring in the brains of people with Alzheimer’s disease are substan- tial, we must use caution in assuming they represent qualitative differences from normal aging. They may not. As we saw in Chapter 3 , all the changes seen in Alzheimer’s disease, including the structural and neu- rotransmitter changes are also found in normal older adults. To be sure, the changes in Alzheimer’s disease are much greater. But the important point is Alzheimer’s disease may be merely an exaggeration of normal aging and not something qualitatively different from it.
Recent research also implicated certain neuro- chemicals as other possible causes of Alzheimer’s dis- ease. Increased levels of plasma homocysteine have been associated with the level of cognitive impairment
observed in Alzheimer’s disease (Blasko et al., 2008; Bleich et al., 2003). Screening for these increased levels may improve diagnostic accuracy, and these levels are directly addressed by medication with memantine (dis- cussed later).
Symptoms and Diagnosis. The major symptoms of Alzheimer’s disease are gradual changes in cognitive functioning: declines in memory beginning with loss of recent memory and progressing to loss of remote mem- ory, learning, attention, and judgment; disorientation in time and space; difficulties in word finding and com- munication; declines in personal hygiene and self-care skills; inappropriate social behavior; and changes in personality (American Psychiatric Association, 2000).
These symptoms tend to be vague in the begin- ning, and mimic other psychological problems such as depression or stress reactions. An executive may not be managing as well as she once did and may be missing deadlines more often. Slowly, the symptoms get worse. This executive, who could easily handle mil- lions of dollars, can no longer add two small numbers.
Figure 10.3 Action of beta-amyloid and tau proteins in relation to neurons. Each disrupts neurons, but in different ways. Source: http://www.nytimes.com/interactive/2012/02/02/science/in-alzheimers-a-tangled-protein.html
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 291
A homemaker cannot set the table. A person who was previously outgoing is now quiet and withdrawn; a gentle person is now hostile and aggressive. Emotional problems become increasingly apparent, including depression, paranoia, and agitation. Wandering becomes a serious problem, especially because the person may have no idea where he or she is or how to get home, thus posing a genuine safety concern. Neuroscience research indicates wandering likely results from damage to the specific parts of the brain that help us navigate through the world (the entorhinal cortex), an area usually dam- aged in the early stages of Alzheimer’s disease (Jacobs, Weidemann, Miller, Solway, Burke, Wei et al., in press).
As the disease progresses, the patient becomes incontinent and more and more dependent on others for care, eventually becoming completely incapable of such simple tasks as dressing and eating. In general, the symptoms associated with Alzheimer’s disease are worse in the evening than in the morning, a phenomenon care providers call sundowning .
The rate of deterioration in Alzheimer’s disease varies widely from one patient to the next, although progression usually is faster when onset occurs ear- lier in life (Gandy & DeKosky, 2013). Alzheimer’s dis- ease has an average duration of 9 years (but can range anywhere from 1 to over 15 years) from the onset of noticeable symptoms through death (Zerr, 2013). The early stage is marked especially by memory loss,
disorientation to time and space, poor judgment, and personality changes. The middle stage is characterized by increased memory problems, increased difficulties with speech, restlessness, irritability, and loss of impulse control. People in the late stage of Alzheimer’s disease experience incontinence of urine and feces, lose motor skills, have decreased appetite, have great difficulty with speech and language, may not recognize family mem- bers or oneself in a mirror, lose most if not all self-care abilities, and decreased ability to fight off infections.
Although a definitive diagnosis of Alzheimer’s dis- ease depends on an autopsy, the number and severity of neurological and behavioral changes allow clinicians to make increasingly accurate early diagnoses (Feldman et al., 2008). For an earlier diagnosis to be accurate, how- ever, it must be comprehensive and broad. Figure 10.4 provides an overview of the process used to differenti- ate Alzheimer’s disease from other conditions. Note a great deal of the diagnostic effort goes into ruling out other possible causes for the observed cognitive deficits: All possible treatable causes for the symptoms must be eliminated before a diagnosis of Alzheimer’s disease can be made. Unfortunately, many clinicians do not con- duct such thorough diagnoses; general practice physi- cians fail to accurately diagnose a significant number of cases of Alzheimer’s disease (Bradford, Kunik, Schulz, Williams, & Singh, 2009). A common reason is the atti- tude on the part of some physicians that early diagnosis
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292 CHAPTER 10
does more harm than good based on the mistaken belief patients and their families would prefer not to know or could not adequately deal with it; both are untrue.
As noted in Figure 10.4 , the clinical diagnosis of Alzheimer’s disease consists of carefully noting the his- tory of the symptoms, documenting the cognitive impairments, conducting a general physical exam and neurological exam, performing laboratory tests to rule
out other diseases, obtaining a psychiatric evaluation, performing neuropsychological tests, and assessing func- tional abilities.
As noted in the Current Controversies feature, there is considerable debate over the criteria that should be used to diagnose Alzheimer’s disease, and whether there should be a diagnosis even before there are any measurable behavioral symptoms.
Figure 10.4 Process of differentially diagnosing Alzheimer’s disease from other possible conditions. Source : Alzheimer’s Association online document. http://www.alz.org/medical/rtalgrthm.htm Developed and endorsed by the TriAD Advisory Board. Copyright 1996 Pfizer Inc. and Esai Inc. with special thanks to J. L. Cummings. Algorithm reprinted from TriAD, Three for the Management of Alzheimer’s Disease, with permission.
Medication-induced dementia Reduce or change medication
If no improvement in cognition after treatment
Progressive change in memory or function
Dementia
Medication review
Depression—treat
If no improvement in cognition
Depressed mood
Atypical disorders†
Refer for assessment
Alzheimer’s disease
Hypothyroidism B12 deficiency Systemic illness
If no improvement in cognition after treatment
AbnormalAbnormal laboratory tests Abnormal physical exam
Vascular dementia Hydrocephalus Tumors Subdural hematoma
Minor vascular changes
Abnormal
Yes
CT or MRI (optional)*
*It is required in patients with focal signs, rapid progression, and headache. †This category contains rare dementias (e.g., frontotemporal degenerations, Jakob–Creutzfeldt disease, Parkinson’s disease, and other movement disorders that present with dementias) that should be considered when unusual clinical features are present or a rapidly progressive course is noted.
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 293
CURRENT CONTROVERSIES: NEW DIAGNOSTIC CRITERIA FOR ALZHEIMER’S DISEASE The diagnostic criteria for Alzheimer’s disease currently in use were established in 1984. They are outdated because of the tremendous amount of research done since then has greatly expanded our knowledge of what Alzheimer’s disease is, what causes it, and how it develops and progresses. As a result of pressure from clinicians and researchers for revised criteria, in 2011 a draft of new criteria developed jointly by the National Institute on Aging and the Alzheimer’s Association were released (Jack, Albert, Knopman, McKhann, Sper- ling, Carrillo et al., 2011).
The draft criteria created a firestorm. Research indicated that Alzheimer’s disease progresses through a series of stages, from a “preclinical” phase when no symptoms can be detected, through mild cognitive impairment, to the various stages of Alzheimer’s disease (Albert, DeKosky, Dickson, Dubois, Feldman, Fox et al., 2011; Jack et al., 2011; McKhann, Knopman, Chertkow,
Hyman, Jack, Kawas et al., 2011; Sperling, Aisen, Beck- ett, Dennett, Craft, Fagan et al., 2011). Additionally, the draft called for biomarkers to be associated with each of the various categories. How these elements fit together is shown in Figure 10.5 .
What set off the controversy was whether peo- ple should be diagnosed with a “preclinical” form of Alzheimer’s disease. Many clinicians objected to label- ing individuals who had not shown any behavioral symptoms with a form of an incurable disease when many, perhaps most of them would not subsequently develop full-blown Alzheimer’s disease (Chiu & Brodaty, 2013).
Research clearly shows a number of potential biomarkers can be associated with Alzheimer’s dis- ease (Chong & Lee, 2013). However, many who show high levels of beta-amyloid protein do not go on to develop Alzheimer’s disease. This complicates the issue of whether to intervene during this preclinical stage in order to potentially “prevent” a disease that may never develop, or whether to run the risk of not intervening and the person in fact subsequently develops a devas- tating disease.
Normal aging MCI
¬ Brain structure (volumetric MRI) ®
¬ Synaptic dysfunction (FDG-PET / fMRI) ®
¬ Tau-mediated neuronal injury (CSF) ®
¬ Histopathological AD changes (amyloid plaques & neurofibrillary tangles) ®
Mild AD Moderate AD Severe AD
CDR 3CDR 2CDR 1CDR 0.5
? Blood biomarkers and associated biochemical change
CDR 0
Downstream measures of Structural and Functional or Metabolic Change
Biomarkers of Molecular Neuropathology of AD
Asymptomatic individuals with histopathologic
AD changes
Figure 10.5 Clinical continuum of Alzheimer’s disease showing types of changes over time. Blood biomarkers and associated biochemical changes are the focus of current research. AD = Alzheimer’s disease ; MCI = Mild Cognitive Impairment ; CDR = Clinical Dementia Rating ( a measure of severity of symptoms ) ; FDG- PET = Positron Emission Tomography scan using 18-FDG as the tracer molecule ; fMRI = Functional Magnetic Resonance Imaging ; CSF = cerebrospinal fluid . Source: Chong, S., & Lee, T.-S. (2013). Predicting cognitive decline in Alzheimer’s disease (AD): The role of clinical, cognitive characteristics and biomarkers. In I. Zerr (Ed.), Understanding Alzheimer’s disease (pp. 375–408). Retrieved from http://www.intechopen.com/books/understanding-alzheimer-s-disease . doi: 10.5772/54289. Figure 1, p. 376.
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294 CHAPTER 10
Searching for a Cause. We do not know for certain what causes Alzheimer’s disease. What we do know is that certain forms of Alzheimer’s disease are caused by autosomal dominant genes related to beta-amyloid protein production (Gandy & DeKosky, 2013). Auto- somal dominant inheritance patterns are those that involve only one gene from either one’s mother or father in order to cause a trait or condition to develop. Auto- somal dominant forms of Alzheimer’s disease usually involve mutations in the presenillin 1 (PSEN1) and amyloid beta (A4) precursor protein (APP) genes. The strong possibility at least some forms of Alzheimer’s disease are inherited is a major concern of patients’ families.
Other genetic causes involve the complex inter- action of several genes, processes that are not yet well documented or understood. Several sites on various chromosomes have been tentatively identified as being involved in the transmission of Alzheimer’s disease, including chromosomes 12 , 14 , 19 , and 21 . The most promising work noted links between the genetic mark- ers and the production of amyloid protein, the major component of neuritic plaques (Liu, Kanekiyo, Xu, & Bu, 2013). Much of this research focuses on apoli- poprotein E4 (apo E4), associated with chromosome 19 , that may play a central role in creating neuritic plaques. People with the apo E4 trait are more likely to get Alzheimer’s disease than those with the more common apo E3 trait. Additionally, a related mutation (TREM2) may be involved with apo E4 as well by inter- fering with the brain’s ability to contain inflammation (Jonsson, Stefansson, Steinberg, Jonsdottir, Jonsson, Snaedal et al., 2013).
Interestingly, another version, apo E2, seems to have the reverse effect from apo E4: It decreases the risk of Alzheimer’s disease (Liu et al., 2013). Despite the relation between apo E4 and neuritic plaques, and between apo E4 and beta-amyloid buildup, researchers have yet to establish strong relations directly between apolipoprotein E and general cognitive functioning (Liu et al., 2013).
Much of the genetics and related biomarker research focused on beta-amyloid and its proposed relation to Alzheimer’s disease reviewed earlier. When viewed as a cause of Alzheimer’s disease, researchers refer to the beta-amyloid cascade hypothesis as the process by which this occurs (Reitz, 2012). The beta- amyloid cascade hypothesis refers to the process by which beta-amyloid deposits create neuritic plaques, that in turn lead to neurofibrillary tangles, that cause neuronal death and, when this occurs severely enough, Alzheimer’s disease . As noted earlier, there is consider- able evidence beta-amyloid is involved in Alzheimer’s disease. However, there is insufficient evidence at this point to conclude it is the main cause (Reitz, 2012).
Other research regarding the cause(s) of Alzheim- er’s disease is focusing on the role of changes in the vas- cular system in the brain. Beason-Held and colleagues (e.g., Beason-Held, Thambisetty, Deib, Sojkova, Land- man, Zonderman et al., 2012; Codispoti, Beason-Held, Kraut, O’Brien, Rudow, Pletnikova et al., 2012; Thambi- setty, Beason-Held, An, Kraut, Nalls, Hernandez et al., 2012) discovered increased blood flow in the frontal cortex, combined with decreased blood flow in the parietal and temporal lobes, resulted in significant cog- nitive impairment. Interestingly, the changes in blood flow occurred prior to measurable changes in cognitive functioning. Alternatively, de la Monte (2012) argues Alzheimer’s disease is caused at least in part by impair- ment in the brain’s ability to use glucose and produce energy. De la Monte found processed foods containing nitrites and high fat may exacerbate cognitive decline. Support for this idea comes from research showing that high blood sugar (glucose) levels are correlated with increased risk of Alzheimer’s disease even in people without diabetes (Crane, Walker, Hubbard, Li, Nathan, Zheng et al., 2013). These results go further than previ- ous findings showing that diabetes is a risk factor for Alzheimer’s disease (Vagelatos & Eslick, 2013).
Because researchers can identify definite bio- markers responsible for certain forms of early-onset Alzheimer’s disease, they have been able to develop
Until we have definitive evidence of a specific set or pattern of biomarkers that inevitably result in the full clinical manifestation of Alzheimer’s disease,
though, whether we should identify those who may be “at risk” with a label of a disease will remain highly controversial.
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 295
genetic screening tests to see whether people have the inheritance pattern (McQueen & Blacker, 2008). Although research shows no significant negative conse- quences to people when they know they have the marker for Alzheimer’s disease (Marteau et al., 2005), difficult choices may remain. Individuals who know they have the genes responsible for the disease may be faced with difficult decisions about having children and how to live out their lives. Genetic counseling programs that currently focus mostly on diseases of childhood would need to be expanded to help individuals face deci- sions about diseases occurring later in life. As research advances continue to improve our understanding of the causes of Alzheimer’s disease, additional tests may be forthcoming. Helping people understand the true risks of developing (or, equally important, not developing) Alzheimer’s disease will be an increasingly important focus of genetic counseling programs.
Intervention Strategies: Medications. Alzheimer’s disease is incurable. However, much research has been done to find medications to alleviate the cognitive def- icits and behavioral problems that characterize the dis- ease. The flurry of research on biomarkers, especially beta-amyloid and tau proteins, has led to research on potential medication treatments based on blocking their effects on the brain (Lane, Dacks, Shineman, & Fillit, 2013). No medications that prevent the buildup of either beta-amyloid or tau proteins are available yet, but there is expectation a breakthrough will occur in the next several years.
In the meantime, research also continues on various drugs that improve memory and alleviate the declines that occur in Alzheimer’s disease, especially in the early and middle stages. Currently, there are two groups of medications approved by the Food and Drug Administration for use with Alzheimer’s disease patients: cholinesterase inhibitors that affect the levels of the neurotransmitter acetylcholine (such as donepe- zil [Aricept®], galantamine [Razadyne®], and rivastig- mine [Exelon®]), and memantine (Namenda®) that works on other neurotransmitters and sets of neurons. Unfortunately, none of the drugs is highly effective, especially in later stages of the disease.
Intervention Strategies: Behavioral. To date, the most effective interventions for Alzheimer’s disease
are behavioral strategies; these approaches are recom- mended over medications because they give better and more effective outcomes (Gitlin, Kales, & Lyketsos, 2012). These strategies can be used from the time of initial diagnosis throughout the duration of the disease.
Key steps to be taken once a diagnosis is made include:
obtaining accurate information about the disease, involving the patient as much as possible in deci-
sions about his or her care, identifying the primary care provider, assessing the patient’s living situation, setting realistic goals, making realistic financial plans, identifying a source of regular medical care, maximizing the patient’s opportunity to function
at his or her optimal level, making realistic demands of the patient, and using outside services as needed.
The goal of these early steps is to build a broad sup- port network of relatives, medical personnel, and service providers that may be needed later. The new responsi- bilities of family members require changes in daily rou- tines; people adjust to these roles at different rates.
When they find themselves caring for a person with Alzheimer’s disease, care providers must rethink many behaviors and situations they otherwise take for granted. Dressing, bathing, and grooming become more difficult or even aversive to the affected person. Use of Velcro fasteners, joining the person during a bath or shower, and other such changes may be nec- essary. Nutritional needs must be monitored, because people with dementia may forget they have just eaten or may forget to eat.
Medications must be used with caution, since patients may forget to taken them or forget they have taken them and take another dose. Changes in person- ality and sexual behavior must be viewed as part of the disease. Sleeplessness can be addressed by establishing consistent bedtimes, giving warm milk or tryptophan before bedtime, and limiting caffeine intake. Wander- ing is especially troublesome because it is difficult to
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control; making sure the affected person has an iden- tification bracelet with the nature of the problem on it and making the house accident-proof are two preven- tive steps. In severe cases of wandering it may be nec- essary to use restraints under the direction of a health care professional.
Incontinence, that usually occurs late in the dis- ease, is a troubling and embarrassing issue for the person with dementia; use of special undergarments or medications to treat the problem are two options. Incontinence is not necessarily related to Alzheimer’s disease; stress incontinence, that is fairly common among older women, is unrelated to dementia.
Many care providers need to learn how to accom- plish these tasks. Programs providing basic care information are available in multiple formats, includ- ing onsite face-to-face and online. A comparison of in-person and online formats in Hong Kong showed no differences in effectiveness (Lai, Wong, Liu, Lui, Chan, & Yap, 2013). Burgio and colleagues (2003) showed such skills training is effective for European Ameri- can and African American care providers, and reduces
the number of problem behaviors the care providers must face from care recipients. Similarly, European American and Latino care providers both reported sig- nificant reductions in depressive symptoms, increased use of adaptive coping, and decreased use of negative coping strategies after training and practice in the use of specific cognitive and behavioral skills (Gallagher- Thompson et al., 2003). Additionally, home interven- tion strategies can result in care providers having more time to themselves and a decrease in the amount of assistance they need from external sources (Nichols et al., 2008).
One of the most difficult issues care providers face concerns taking things away from the affected person and restricting activity. For example, in many cases the person experiences problems handling finances. It is not uncommon for them to spend hundreds or even thousands of dollars on strange items, to leave the checkbook unbalanced and bills unpaid, and to lose money. Although they can be given some money to keep, someone else must handle the day-to-day accounts. That transition may be traumatic, and the caregiver may be accused of trying to steal money.
Traveling alone is another difficult issue. Families of people with dementia often do not recognize their loved one’s deteriorating condition until a calamity occurs during travel. Families should limit solo excur- sions to places within walking distance; all other trips should be made with at least one family member along. Related to this, driving is often a contentious issue, especially if the person does not recognize his or her limitations. Once it is clear the patient cannot drive, the family must take whatever steps are necessary. In some cases this entails simply taking the car keys, but in oth- ers it becomes necessary to disable the car. Suggesting the patient could be chauffeured is another alternative. In any case, care providers may be subjected to various sorts of accusations related to these issues.
How can family members and health care profes- sionals deal with the behavioral and cognitive problems experienced by people with Alzheimer’s disease? One successful approach for dealing with difficult behav- ior is a technique called differential reinforcement of incompatible behavior (DRI) (Fisher et al., 2008). In DRI, care providers reduce the incidence of difficult behavior by rewarding the person with Alzheimer’s disease for engaging in appropriate behaviors that
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 297
cannot be done at the same time as the problem behav- iors. For example, a person who throws food during dinner could be rewarded for sitting quietly and eat- ing. One major advantage of DRI for care providers is the technique can be used in the home, and provides a good way to deal with troublesome behaviors (Fisher et al., 2008). Most important, the DRI technique is eas- ily learned, has no side effects, and can be as effective as or more effective than medical treatments (Spira & Edelstein, 2006).
Numerous effective behavioral and educational interventions have been developed to address the memory problems in early and middle-stage demen- tia. One behavioral intervention involves using an implicit-internal memory intervention called spaced retrieval . Developed by Camp and colleagues (e.g., Camp, 2001), spaced retrieval involves teaching per- sons with Alzheimer’s disease to remember new infor- mation by gradually increasing the time between retrieval attempts (see Chapter 6 for more details). This easy, almost magical technique has been used to teach names of staff members and other information;
it holds considerable potential for broad application at home and in any residential care setting. It is eas- ily taught to any care provider (Hunter et al., 2012). Research also shows combining spaced retrieval with additional memory encoding aids helps even more (Kinsella et al., 2007). Spaced retrieval also works in training non-memory behaviors; spaced retrieval can be used with residents with dementia who have trou- ble swallowing to help them relearn how to swallow (Camp, Antenucci, Brush, & Slominski, 2012).
In designing interventions for persons with Alzheimer’s disease, the guiding principle should be optimizing the person’s functioning. Regardless of the level of impairment, attempts should be made to help the person cope as well as possible with the symptoms. The key is helping all persons maintain their dignity as human beings. This can be achieved in creative ways, such as adapting the principles of Montessori methods of education to bring older adults with Alzheimer’s disease together with preschool children so they perform tasks together (Malone & Camp, 2007). One example of this approach is discussed in the How Do We Know? feature.
HOW DO WE KNOW?: TRAINING PERSONS WITH DEMENTIA TO BE GROUP ACTIVITY LEADERS Who were the investigators, and what was the aim of the study? Dementia is marked by progressive and severe cognitive decline. But despite these losses, can people with dementia be trained to be group leaders? Most people might think the answer is “no,” but Cam- eron Camp and Michael Skrajner (2005) decided to find out by using a training technique based on the Montes- sori method.
How did the investigators measure the topic of interest? The Montessori method is based on self-paced learning and developmentally appropriate activities. As Camp and Skrajner point out, many techniques used in rehabilitation (e.g., task breakdown, guided repeti- tion, moving from simple to complex and concrete to abstract) and in intervention programs with people who have dementia (e.g., use of external cues and implicit memory) are consistent with the Montessori method.
For this study, a program was developed to train group leaders for Memory Bingo (see Camp, 1999a and 1999b, for details about this game). Group lead- ers learned what cards to pick for the game, where the answers were located on the card, where to “discard”
the used (but not the winning) cards, and where to put the winning cards. Success in the program was mea- sured by research staff raters, who made ratings of the type and quality of engagement in the task shown by the group leader.
Who were the participants in the study? Camp and Skrajner tested four people who had been diagnosed as probably having dementia who were also residents of a special care unit of a nursing home.
What was the design of the study? The study used a longitudinal design so Camp and Skrajner could track participants’ performance over several weeks.
Were there ethical concerns with the study? Having persons with dementia as research partici- pants raises important issues with informed consent. Because of their serious cognitive impairments, these individuals may not fully understand the procedures. Thus, family members such as a spouse or adult child caregiver are also asked to give informed consent. Additionally, researchers must pay careful attention to participants’ emotions; if participants become agi- tated or frustrated, the training or testing session must be stopped. Camp and Skrajner took all these precautions.
What were the results? Results showed at least par- tial adherence to the established game protocols was achieved at a high rate. Indeed, staff assistance was not
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The key conclusion is behavioral intervention strategies are powerful tools to assist care providers in helping people deal with Alzheimer’s disease. Hav- ing essentially no side effects and easy to learn how to administer, these strategies should be the first option tried.
Caring for Patients with Dementia at Home. Watching a loved one struggle with Alzheimer’s dis- ease can be both heartrending and uplifting for family members (O’Dell, 2007). Watching a spouse, parent, or sibling go from being an independent, mature adult to not remembering the names of family members is extremely difficult. But the unconditional love shown by family care providers and the opportunity for fam- ily members to develop closer relationships can be quite positive. In this section, we consider some of the key issues regarding caregiving for persons with dementia; we consider caregiving more generally in Chapter 11 .
Most people with dementia (as well as other impairments) are cared for by their family members at home (MetLife Mature Market Institute, 2012). Over 10 million adults over age 50 provide more than 20 hours per week on average in unpaid care for relatives; this is estimated to be worth well over $ 300 billion annually. Most care providers are over age 50 and are working, mostly full time. Care providers lose about $ 3 trillion in wages, pensions, and Social Security payments when they take time off work to care for a loved one (MetLife Mature Market Insti- tute, National Alliance for Caregiving, and Center for Long-Term Care Research, 2011). Women aver- age about $ 324,000 and men average about $ 290,000 in losses; women’s losses are greater even though they generally earn less because they take more time off. Care providers tend to be of moderate financial means, with many being poor.
One useful way to conceptualize family caregiving is as an unexpected career (Aneshensel et al., 1995). The caregiving career begins with the onset of the ill- ness and moves through a number of separate steps. Note the process does not end with the placement of the affected family member in a nursing home, or even with that person’s death. Rather, the career con- tinues through the bereavement and social readjust- ment period, at which point one may continue with life. Observe the kind of caregiving changes, from the comprehensive caregiving that covers all aspects of the process, to sustained caregiving in the home and foreshortened caregiving in the nursing home, to with- drawal from caregiving.
Research documented care providers are at risk for depression (Blom, Bosmans, Cuijpers, Zarit, & Pot, 2013; Cox, 2013). It is important care providers who show depressive symptoms receive appropriate treat- ment for it. Whether this support is provided in a tradi- tional face-to-face setting or online does not appear to matter, as demonstrated in a study in the Netherlands (Blom et al., 2013).
Taking care of a person with dementia is usually stressful for families. As you can imagine, family mem- bers who care for a parent with dementia while also holding down a job and raising children puts incred- ible demands on time. Two options available to pro- vide some relief for care providers are respite care and adult day care.
Respite care is designed to allow family mem- bers to get away from the caregiving situation for a time. It can consist of in-home care provided by professionals or temporary placement in a residen- tial facility. In-home care is typically used to allow care providers to do errands or have a few hours free, whereas temporary residential placement is usually reserved for a more extended respite, such as a week- end. Research documents using respite care is a help
required at all for most of the game sessions for any leader. All of the leaders said they enjoyed their role, and one recruited another resident to become a leader in the next phase of the project.
What did the investigators conclude? It appears persons with dementia can be taught to be group activity leaders through a procedure based on the
Montessori Method. This is important since it provides a way for such individuals to become engaged in an activ- ity and to be productive.
Although more work is needed to continue refin- ing the technique, applications of the Montessori method offer a promising intervention approach for people with cognitive impairments.
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 299
to care providers (Roberto & Jarrott, 2008; Zarit & Femia, 2008).
Adult day care provides placement and program- ing for frail older adults during the day. The goal of adult day care is to delay institutionalization, enhance self-esteem, and encourage socialization (Administra- tion on Aging, 2012). Adult day care typically provides more intensive intervention than respite care. This option is used most often by adult children who are employed. In general, adult day care is an effective approach for care providers (Roberto & Jarrott, 2008).
The demand for respite and adult day care far exceeds their availability, making them limited options. An additional problem is many insurance programs do not pay for these services, making them too expensive for care providers with limited finances. Clearly, with the increase in numbers of people who have dementia, ways to provide support for assistance to family care providers must be found.
Other Forms of Dementia. As we noted, dementia is a family of different diseases. We consider several of them briefly.
Vascular Dementia. Until it was discovered that Alzheimer’s disease was not rare, most physicians and researchers believed most cases of dementia resulted from cerebral atherosclerosis and its consequent restriction of oxygen to the brain. As described in Chapter 3 , atherosclerosis is a family of diseases that, if untreated, may result in heart attacks or strokes. For the present discussion it is the stroke, or cerebrovas- cular accident (CVA), that concerns us. CVAs (see Chapter 3 ) result from a disruption of the blood flow, called an infarct that may be caused by a blockage or hemorrhage.
A large CVA usually produces rapid, severe cogni- tive decline, but this loss is almost always limited to specific abilities. This pattern differs from the classic, global, more gradual deterioration seen in Alzheimer’s disease. If a person experiences numerous small cerebral vascular accidents, a disease termed vascular demen- tia may result. Vascular dementia may have a sudden onset after a CVA, and its progression is described as stepwise and highly variable across people, especially early in the disease. Again, this is in contrast to the similar cluster of cognitive problems shown by people
with Alzheimer’s disease. Most people who have vas- cular dementia have a history of cerebrovascular or cardiovascular disease, and typical symptoms include hypertension, specific and extensive alterations on an MRI, and differential impairment on neuropsycho- logical tests (a pattern of scores showing some func- tions intact and others significantly below average; Paul, Lane, & Jefferson, 2013). Individuals’ specific symptom patterns may vary a great deal, depending on which specific areas of the brain are damaged. In some cases, vascular dementia has a much faster course than Alzheimer’s disease, resulting in death an average of 2 to 3 years after onset; in others, the disease may prog- ress much more slowly with idiosyncratic symptom patterns.
Parkinson’s Disease. Parkinson’s disease is known primarily for its characteristic motor symptoms that are easily seen: very slow walking, difficulty get- ting into and out of chairs, and a slow hand tremor. Research indicates these problems are caused by a deterioration of neurons that produce the neu- rotransmitter dopamine. Dopamine is involved in transmitting messages between the brain structure called the substantia nigra and other parts of the brain to enable us to have smooth body movements. When roughly 60 to 80 % of the dopamine-producing cells are damaged, and do not produce enough dopa- mine, the motor symptoms of Parkinson’s disease appear.
However, motor system changes may not be the most important diagnostically. One prominent theory is the earliest indications of Parkinson’s are found in a different part of the brain, the medulla and the olfac- tory bulb, which controls the sense of smell. Accord- ing to this theory, Parkinson’s only progresses to the substantia nigra and cortex over many years. In fact, there is evidence non-motor symptoms such as a loss of sense of smell, sleep disorders, and constipation may precede the motor features of the disease by several years (Hoyles & Sharma, in press; National Parkinson’s Foundation, 2012).
Former boxing champion Muhammad Ali and actor Michael J. Fox are some of the more famous indi- viduals who have Parkinson’s disease. Parkinson’s dis- ease is diagnosed in 40,000 to 50,000 people each year (National Parkinson’s Foundation, 2012).
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Symptoms are treated effectively with several medications (Parkinson’s Disease Foundation, 2013); the most popular are levodopa, which raises the func- tional level of dopamine in the brain; Sinemet® (a com- bination of levodopa and carbidopa), that gets more levodopa to the brain; and Stalevo® (a combination of Sinemet® and entacapone), that extends the effective dosage time of Sinemet®. Research indicates a device called a neurostimulator, that acts like a brain pace- maker by regulating brain activity when implanted deep inside the brain, may prove effective in signifi- cantly reducing the tremors, shaking, rigidity, stiffness, and walking problems when medications fail (Schuep- bach, Rau, Knudsen, Volkman, Krack, Timmerman et al., 2013).
For reasons we do not yet understand, some people with Parkinson’s disease also develop severe cognitive impairment and eventually dementia (Zheng, Shemmassian, Wijekoon, Kim, Bookheimer, & Poura- tian, in press). As with Alzheimer’s disease, attention is focused on beta-amyloid protein levels as a possible cause, but much work remains to be done (Beyer, Alves, Hwang, Babakchanian, Bronnick, Chou et al., 2013).
Huntington’s Disease. Huntington’s disease is an autosomal dominant disorder that usually begins between ages 30 and 45 (Sharon et al., 2007). The dis- ease generally manifests itself through involuntary flicking movements of the arms and legs; the inability to sustain a motor act such as sticking out one’s tongue; prominent psychiatric disturbances such as halluci- nations, paranoia, and depression; and clear person- ality changes, such as swings from apathy to manic behavior.
Cognitive impairments typically do not appear until late in the disease. The onset of these symptoms is gradual. The course of Huntington’s disease is pro- gressive; patients ultimately lose the ability to care for themselves physically and mentally. Walking becomes impossible, swallowing is difficult, and cognitive loss becomes profound. Changes in the brain thought to underlie the behavioral losses include degeneration of the caudate nucleus and the small-cell population, as well as substantial decreases in the neurotransmit- ters g-aminobutyric acid (GABA) and substance P. A test is available to determine whether someone has the marker for the Huntington’s disease gene.
Alcohol-Related Dementia. Chronic alcohol abuse or dependence may result in cognitive decline, ranging from limited forms of amnesia or mild cognitive impairment to dementia (Ridley, Draper, & Withall, 2013). The causes of these memory problems include deficiency of nutritional factors (such as B-complex vitamins) that cause Wernicke- Korsakoff ’s syndrome, and/or other problems such as cerebrovascular disease. However, progressive cognitive impairment can occur in the absence of syndromes such as Wernicke-Korsakoff ’s, and has been attributed to the direct toxic effect of ethanol on the brain.
One key symptom of alcohol-related dementia is confabulation, when the person makes up what sounds believable, but completely fictitious, stories that cover the gaps in memory. Other symptoms include person- ality changes (e.g., frustration, anger, suspicion, and jealousy), loss of problem-solving skills, communica- tion problems (e.g., word-finding difficulty), and dis- orientation to time and place. Early in the course of the disease, the memory problems may be reduced or reversed if the person stops drinking alcohol, eats a well-balanced diet, and is given vitamin replacements (especially thiamine and vitamin B1). Thiamine, that limits some of the toxic effects of alcohol, is an impor- tant supplement for heavy drinkers.
AIDS Dementia Complex. AIDS dementia complex (ADC), or HIV-associated encephalopathy, occurs primarily in persons with more advanced HIV infec- tion (Manji, Jäger, & Winston, in press). The virus does not appear to directly invade nerve cells, but it jeopardizes their health and function. The resulting inflammation may damage the brain and spinal cord and cause symptoms such as confusion and forgetful- ness, behavioral changes (e.g., apathy, loss of sponta- neity, depression, social withdrawal, and personality changes), severe headaches, progressive weakness, loss of sensation in the arms and legs, and stroke. Cognitive motor impairment or damage to the peripheral nerves is also common.
Research shows the HIV infection can sig- nificantly alter the size of certain brain structures involved in learning and information processing. Symptoms include encephalitis (inflammation of the brain), behavioral changes, and a gradual decline in
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 301
10.4 Other Mental Disorders and Concerns LEARNING OBJECTIVES
What are the symptoms of anxiety disorders? How are they treated?
What are the characteristics of people with psychotic disorders?
What are the major issues involved with substance abuse?
Daisy forces herself to do her daily routine. She is shaky all the time because she just doesn’t feel safe. Her neighborhood is deteriorating and she is afraid of what the teenagers will do to her. She imagines all sorts of hor- rible things. Her worst fear is no one would know if she was attacked or fell ill. Her heart races when she thinks about it. She rarely goes out now and has convinced her son to bring her groceries and other supplies.
Daisy’s feelings indicate people have difficul- ties for many reasons. She is clearly afraid, that could reflect a realistic assessment of her neighborhood. But her feelings also make her heart race, which is unusual. In this section, we examine three disorders receiving increased attention: anxiety disorders, psychotic disor- ders, and substance abuse.
cognitive function, including trouble with concentra- tion, memory, and attention. Persons with ADC also show progressive slowing of motor function and loss of dexterity and coordination. When left untreated, ADC can be fatal. In the terminal phase of ADC, patients are bedridden, stare vacantly, and have minimal social and cognitive interaction.
Because HIV infection is largely preventable, ADC can be reduced through the practice of safe sex. Additionally, research shows aggressive treatment of HIV with antiretroviral medications can also dramati- cally reduce the risk of subsequently developing ADC (Manji et al., in press).
Anxiety Disorders Imagine you are about to give a speech before an audience of 500 people. In the last few minutes before your address, you begin to feel nervous, your heart starts to pound, and your palms get sweaty. (You now have something in common with Daisy’s reactions.) These feelings, common even to veteran speakers, are similar to those experienced by people with anxi- ety disorders: a group of conditions based on fear or uneasiness.
Anxiety disorders include problems such as feel- ings of severe anxiety for no apparent reason, phobias with regard to specific things or places, and obsessive– compulsive disorders, when thoughts or actions are repeatedly performed (Segal et al., 2010). Although anxiety disorders occur in adults of all ages, they are particularly common in older adults because of loss of health, relocation stress, isolation, fear of losing inde- pendence, and many other reasons. Anxiety disorders are diagnosed in approximately 17 % of older men and 21 % of older women making them relatively common (Fitzwater, 2008). The reasons for this gender differ- ence are unknown.
Symptoms and Diagnosis of Anxiety Disorders. Common to all the anxiety disorders are physical changes that interfere with social functioning, personal relationships, or work. These physical changes include dry mouth, sweating, dizziness, upset stomach, diar- rhea, insomnia, hyperventilation, chest pain, choking, frequent urination, headaches, and a sensation of a lump in the throat (Segal et al., 2010). These symptoms occur in adults of all ages, but they are particularly common in older adults because of loss of health, relo- cation stress, isolation, fear of losing control over their lives, or guilt resulting from feelings of hostility toward family and friends.
An important issue concerning anxiety disor- ders in older adults is anxiety may be an appropriate response to the situation. Helplessness anxiety such as Daisy experiences is generated by a potential or actual loss of control or mastery (Varkal, Yalvac, Tufan, Turan, Cengiz, & Emul, 2013). A study in Turkey showed older adults are anxious about their memory, reflect- ing at least in part a realistic assessment of normative, age-related decline.
Adult Development in Action How are the key distinguishing features of depression, delirium, and dementia important to social workers?
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In addition, a series of severe negative life expe- riences may result in a person’s reaching the break- ing point and appearing highly anxious. Many older adults who show symptoms of anxiety disorder have underlying health problems that may be responsible for the symptoms. In all cases the anxious behavior should be investigated first as an appropriate response that may not warrant medical intervention. The important point is to evaluate the older adult’s behav- ior in context.
These issues make it difficult to diagnose anxiety disorders, especially in older adults (Fitzwater, 2008; Segal et al., 2010). The problem is there usually is nothing specific a person can point to as the specific trigger or cause. In addition, anxiety in older adults often accompanies an underlying physical disorder or illness.
These secondary causes of anxiety must be disentangled from the anxiety symptoms so each may be dealt with appropriately. In short, the trick is to dis- tinguish between the “worried” and the well. Zarit and Zarit (2007) report the key features of late-life anxi- ety disorder are distress and impairment, frequency and uncontrolled worry, muscle tension, and sleep disturbance.
Treating Anxiety Disorders. Anxiety disorders can be treated with medication and psychotherapy
(Hendriks, Keijsers, Kampman, Hoogduin, & Voshaar, 2012; Segal et al., 2010). The most commonly used medications are benzodiazepine (e.g., Valium® and Librium®), paroxetine (an SSRI, e.g.., Paxil®), buspi- rone, and beta-blockers. Though moderately effec- tive, these drugs must be monitored carefully in older adults because the amount needed to treat the disorder is low and the potential for side effects is great.
For older adults, the clear treatment of choice is psychotherapy, specifically cognitive behavioral or relax- ation therapy, especially when anxiety disorders first occur in later life (Hendriks et al., 2012). Relaxation ther- apy is exceptionally effective, easily learned, and presents a technique that is useful in many situations (e.g., falling asleep at night; Segal et al., 2012). The advantage of these psychotherapeutic techniques is they usually involve only a few sessions, have high rates of success, and offer clients procedures they can take with them.
Psychotic Disorders Some forms of psychopathology, called psychoses, involve losing touch with reality and the disintegration of personality. Two behaviors that occur in these disor- ders are delusions, belief systems not based on reality, and hallucinations, distortions in perception.
It is rare older adults develop new cases of psy- chotic disorders (Salai, 2013). The behaviors present in psychotic disorders are commonly manifested as
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 303
secondary problems caused by other disorders, espe- cially in dementia, or as side effects from medications. Thus, psychotic symptoms are an important aspect of the diagnosis of other disorders and can be managed in the same way.
Schizophrenia. Schizophrenia is characterized by the severe impairment of thought processes, including the content and style of thinking, distorted perceptions, loss of touch with reality, a distorted sense of self, and abnormal motor behavior (American Psychiatric Asso- ciation, 1994). People with schizophrenia may show these abnormal behaviors in several ways: loose asso- ciations (such as saying that they have a secret meet- ing with the president of the United States in the local bowling alley), hearing voices that tell them what to do, believing they can read other people’s minds, believing their body is changing into something else, or some- times having bizarre delusions (e.g., that they are Jesus or they are being spied on). In addition, schizophrenic people tend to show little or highly inappropriate emo- tionality (laughing hysterically at the news of a major tragedy, for instance). They are often confused about their own identity, have difficulty working toward a goal, and tend to withdraw from social contact.
The second hallmark symptom of schizophrenia is delusions, or well-formed beliefs not based in real- ity. Most often, these delusions involve persecution (“People are out to get me”). The distinction between paranoid disorders and schizophrenia is fuzzy; indeed, one type of schizophrenia is called paranoid-type schizophrenia. In general, hallucinations, loose asso- ciations, and absent or inappropriate emotions do not occur in paranoid disorders (American Psychiatric Association, 1994).
The beliefs underlying delusions can result in anger, resentment, or even violent acts. Because people with psychoses are extremely suspicious and rarely seek help on their own, such people tend to come to the attention of authorities after having repeated run-ins with the police or neighbors, starting legal proceedings against others on mysterious grounds, or registering complaints about fictitious or distorted events.
The onset of schizophrenia occurs most often between ages 16 and 30 , and much less often after
age 40 (Clare & Giblin, 2008). The symptoms of schizophrenia also differ by age; older adults show less thought disorder and less flattening of their emotions than do younger adults. Some researchers disagree, however, maintaining there are few differ- ences with age in the numbers of people who expe- rience schizophrenic symptoms and no differences in the nature of the symptoms. In any case, there is agreement that new cases of schizophrenia are rare in late life.
Longitudinal research indicates the natural course of schizophrenia is improvement over the adult life span (Salai, 2013; Segal et al., 2012). Stud- ies show the first 10 years of the disorder are marked by cycles of remission and worsening, but symptoms generally lessen in more than half of people with schizophrenia in later life. This may be caused by a rebalancing of the neurotransmitters dopamine and acetylcholine that are heavily weighted toward dopa- mine in younger adults with schizophrenia. Addi- tional rebalancing of other neurotransmitters may also play a role.
Treating Schizophrenia. Traditionally, treatment of schizophrenia has emphasized medication. Drug ther- apy consists of antipsychotics; medications believed to work on the dopamine system (see Chapter 2 ). Some of the more commonly used antipsychotics are halo- peridol (Haldol®), chlorpromazine HCl (Thorazine®), and thioridazine HCl (Mellaril®). These medications must be used with extreme caution in adults of all ages because of the risk of serious toxic side effects, espe- cially the loss of motor control. Despite these risks, antipsychotics often are used in nursing homes and other institutions as tranquilizing agents to control dif- ficult patients.
In general, people with schizophrenia are difficult to treat with psychotherapy. The severe thought dis- turbances characteristic of schizophrenia make it dif- ficult for therapists to work with such clients. Because of their extreme suspiciousness, paranoid people may be reluctant to cooperate in psychotherapy. However, there is evidence a comprehensive and integrated social rehabilitation program combined with health care management intervention can be effective (Pratt, Bartels, Mueser, & Forester, 2008). The goals of therapy
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304 CHAPTER 10
for such people tend to be adaptive rather than cura- tive, helping these people adapt to daily living.
Substance Abuse Although you might think substance abuse is primarily a problem of adolescents and young adults, it’s not— older adults also have the problem (National Institute on Alcohol Abuse and Alcoholism, 2012). Because of the differences in the types of substances abused by younger and older adults (younger adults are more likely to abuse illegal drugs than are older adults), alco- hol provides the best common basis for comparison.
What constitutes alcoholism? Alcoholism, also known as alcohol dependence, is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law. Alcoholism includes four symptoms: craving, impaired control, physical dependence, and tolerance.
As you can see in Figure 10.6 , the prevalence of alcohol dependency drops significantly with age (National Institute on Alcohol Abuse and Alcohol- ism, 2008). However, when data are examined more closely, there are gender and ethnic group differ- ences in alcohol abuse. The percentage of men who abuse alcohol ranges from about 2 times (ages 18 – 29 ) to 6 times (ages 65 and over) higher than those for women. Native Americans have the highest rate of abuse, followed by European Americans, Latinos, African Americans, and Asian Americans (Grant et al., 2004).
Two patterns of onset are evident with older peo- ple with alcohol dependency: early-onset in young adulthood or middle-age lifelong problem drinking, and late-onset problem drinking (Segal et al., 2010). Left untreated, alcohol dependency does not improve over time.
Taking a life-span view of alcohol dependence provides insights into important differences in drink- ing patterns and outcomes (National Institute on Alco- hol Abuse and Alcoholism, 2012). Young adults are more likely to binge drink, and consequently more likely to experience problems such as alcohol poison- ing, drunk-driving offenses, and assaults. The earlier drinking begins, especially if it starts in adolescence, the more likely brain damage occurs and alcohol dependence develops. Young adult drinkers are less likely to feel the effects of alcohol, such as getting sleepy or losing motor coordination, that may result in their drinking more at one time (“binging”). However, young adults’ cognitive performance is more impaired. Taken together, these effects create a dangerous situa- tion—they do not feel the effects as easily, so tend to underestimate the degree they are impaired, and are worse at performing complex tasks such as driving, providing an explanation of why drunk driving is more prevalent among young adults.
Middle age is when the effects of continued alcohol dependence that began in young adulthood become evident. Diseases of the liver, pancreas, and various types of cancer and cardiovascular disease may occur. In part due to these health problems, middle-aged
Figure 10.6 Prevalence of past-year alcohol dependence by age in the United States based on DSM-IV criteria. Source: NIAAA 2001–2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC) data (18–60+ years of age) and Substance Abuse and Mental Administration (SAMHSA) 2003 National Survey on Drug Use and Health (NSDUH) (12–17 years of age).
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 305
adults are the most likely group to seek treatment for their problem.
Drinking among older adults presents a more complicated picture. Even older adults who drink only modest amounts may experience dangerous interac- tions with medications they may be taking. Addi- tionally, they metabolize alcohol much more slowly, meaning it remains in the bloodstream longer. As a result, older adults are at higher risk for abusing alco- hol if they simply continue habits of drinking from earlier points in their lives, even if their consumption when they were younger was only moderate. Diagnos- ing alcohol dependence in older women can be espe- cially difficult given the higher likelihood that they live alone.
Treatment for substance abuse in all age groups focuses on three goals (Segal et al., 2010): stabilization and reduction of substance consumption, treatment of coexisting problems, and arrangement of appropriate social interventions. Which treatment approach works best depends on the age of the person in question (National Institute on Alcohol Abuse and Alcohol- ism, 2012). Younger adults respond best to short-term programs tailored specifically to them; traditional pro- grams such as Alcoholics Anonymous are less effective. On college campuses, these programs target high-risk groups (e.g., fraternities, sororities, athletes) and focus on DUI prevention. Middle-aged adults respond to a variety of approaches, but individual differences are quite large, meaning it may be necessary to try several different treatments. Older adults often respond bet- ter to education programs rather than direct confron- tation to reduce their denial of their problem and to make sure they understand the age-related changes in alcohol metabolism.
What substance abuse treatment options are avail- able in your area? Complete the Discovering Develop- ment feature to find out.
DISCOVERING DEVELOPMENT: WHAT SUBSTANCE ABUSE TREATMENT OPTIONS ARE AVAILABLE IN YOUR AREA? One of the most controversial topics regarding sub- stance abuse is how to deal with people who have the problem. If they use illicit drugs, should they be
Adult Development in Action Find out which treatment options for anxiety disor- ders, psychoses, and substance abuse are available in your region.
treated or jailed? If treatment is the choice, should they be placed in inpatient facilities or in outpa- tient programs? These decisions have become both political and sensitive. Many politicians built their careers on being perceived as “tough on drugs” and vote to curtail or eliminate treatment options for drug offenders. The rise of health management organizations resulted in the near elimination of inpatient treatment facilities in favor of the less expensive outpatient programs and community treatment centers.
An enlightening exercise is to find out what treatment options are available in your area for peo- ple who have substance abuse problems. Find out whether there are any inpatient programs, which outpatient programs and community treatment cen- ters are available, and how long one has to wait to receive treatment. Also, find out the costs of the vari- ous programs and whether health insurance policies cover the treatments.
Gather the information from several geographic regions, and compare program availability. Think about what you would do if you were poor and needed help in your area. What do you think should be done to address the problem?
Social Policy Implications As we have seen, dementia, especially Alzheimer’s disease, takes a devastating toll on the people who have a form of it as well as their family and friends. A significant problem facing the United States (as well as many other countries) is the prospect of a dramatic increase in the number of people with dementia over the next few decades. The problem has many facets: the cost of caring for the individuals with dementia, the lost income and productivity of family care providers, and the lack of prospects for effective treatment or cure in the near future.
Estimates are that 4.7 million people in the United States had Alzheimer’s disease in 2010 (Hebert, Weuve, Scherr, & Evans, 2013). This num- ber is expected to nearly triple by 2050 to about
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306 CHAPTER 10
Summary 10.1 Mental Health and the Adult Life Course
How are mental health and psychopathology defined? Definitions of mental health must reflect appropri-
ate age-related criteria. Behaviors must be interpreted in context. Mentally
healthy people have positive attitudes, accurate perceptions, environmental mastery, autonomy, personality balance, and personal growth.
What key areas are included in a multidimensional approach to assessment?
Considering key biological, psychological, sociocul- tural, and life-cycle factors is essential for accurate diagnosis of mental disorders.
Diagnostic criteria must reflect age differences in symptomatology.
Why are ethnicity and aging important variables to consider in understanding mental health?
Little research has been done to examine ethnic differences in the definition of mental health and psychopathology in older adults.
There is some evidence of different incidence rates across groups.
10.2 Developmental Issues in Assessment and Therapy
What are the key dimensions used for categorizing psychopathology?
Accurate assessment depends on measuring func- tioning across a spectrum of areas, including medi- cal, psychological, and social.
What factors influence the assessment of adults? Negative and positive biases can influence the
accuracy of assessment. The environmental conditions that the assessment
is made can influence its accuracy.
How are mental health issues assessed? Six assessment techniques are used most: interview,
self-report, report by others, psychophysiological assessment, direct observation, and performance- based assessment.
What are some major considerations for therapy across adulthood?
The two main approaches are medical therapy (usually involving drugs) and psychotherapy.
With psychotherapy, clinicians must be sensitive to changes in the primary developmental issues faced by adults of different ages.
Clear criteria have been established for determin- ing “well established” and “probably efficacious” psychotherapies.
10.3 The Big Three: Depression, Delirium, and Dementia
What are the most common characteristics of people with depression? How is depression diagnosed? What causes depression? What is the relation between suicide and age? How is depression treated?
The prevalence of depression declines with age. Gender and ethnic differences in rates have been noted.
Common features of depression include dyspho- ria, apathy, self-deprecation, expressionlessness,
14 million, in large part to the aging of the baby boomers. The cost of care for these individuals will be staggering. The current model of funding cannot sus- tain this level of increase cost (discussed in Chapter 14 ).
Expecting family members to care for loved ones with dementia is not a good option either. Most adult child care providers and many spouse/partner care providers are still employed, and may not have employers that will provide flexible schedules or paid leave. Lost productivity to organizations due to par- ent/spouse/partner care is equivalent to billions of dollars each year. Many insurance plans do not cover behavioral or in-home care options.
The social policy implications of the coming wave of people who will develop dementia are clear. First, research funding aimed at finding an effective way to prevent or cure dementia is essential. Second, redesigning health care plans and service delivery to include behavioral and in-home care along with other more cost-effective alternatives needs to be under- taken. Third, ways for employers to provide support for parent/spouse/partner care need to be found.
The increase in the number of people with demen- tia is only one major aspect of the coming health care crisis resulting from the aging of the baby boomers. We revisit this issue in more detail in Chapter 14 .
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 307
changes in arousal, withdrawal, and several physi- cal symptoms. In addition, the problems must last at least 2 weeks, not be caused by another disease, and negatively affect daily living. Clear age differ- ences exist in the reporting of symptoms. Some assessment scales are not sensitive to age differ- ences in symptoms.
Possible biological causes of severe depression are neurotransmitter imbalance, abnormal brain func- tioning, or physical illness. Loss is the main psycho- social cause of depression. Internal belief systems also are important.
Three families of drugs (SSRIs, HCAs, and MAO inhibitors), electroconvulsive therapy, and various forms of psychotherapy are all used to treat depres- sion. Older adults benefit most from behavior and cognitive therapies.
What is delirium? How is it assessed and treated? Delirium is characterized by a disturbance of con-
sciousness and a change in cognition that develop over a short period of time.
Delirium can be caused by a number of medi- cal conditions, medication side effects, substance intoxication or withdrawal, exposure to toxins, or any combination of factors. Older adults are espe- cially susceptible to delirium.
Most cases of delirium are cured, but some may be fatal.
What is dementia? What are the major symptoms of Alzheimer’s disease? How is it diagnosed? What causes it? What intervention options are there? What are some other major forms of dementia? What do family members caring for patients with dementia experience?
Dementia is a family of disorders. Most older adults do not have dementia, but rates increase signifi- cantly with age.
Alzheimer’s disease is a progressive, fatal dis- ease diagnosed at autopsy through neurological changes that include neurofibrillary tangles and neuritic plaques.
Major symptoms of Alzheimer’s disease include gradual and eventually pervasive memory loss, emotional changes, and eventual loss of motor functions.
Diagnosis of Alzheimer’s disease consists of ruling out all other possible causes of the symptoms. This involves thorough physical, neurological, and neu- ropsychological exams.
Current research suggests Alzheimer’s disease may be genetic, perhaps with an autosomal dominant inheritance pattern, although other hypotheses have been proposed. Much research focuses on beta-amyloid and tau proteins.
Although no cure for Alzheimer’s disease is avail- able, interventions to relieve symptoms are advis- able and possible, including various drug and behavioral interventions. Dealing with declining functioning is especially difficult. Respite and adult day care are two options for care providers.
Vascular dementia is caused by several small strokes. Changes in behavior depend on where in the brain the strokes occur.
Characteristic symptoms of Parkinson’s disease include tremor and problems with walking, along with decreases in the ability to smell. Treatment is done with drugs. Some people with Parkinson’s dis- ease develop dementia.
Huntington’s disease is a genetic disorder that usu- ally begins in middle age with motor and behav- ioral problems.
Alcoholic dementia (Wernicke-Korsakoff syn- drome) is caused by a thiamine deficiency.
AIDS dementia complex results from a by-product of HIV. Symptoms include a range of cognitive and motor impairments.
10.4 Other Mental Disorders and Concerns
What are the symptoms of anxiety disorders? How are they treated?
Anxiety disorders include panic, phobia, and obsessive–compulsive problems. Symptoms include a variety of physical changes that interfere with normal functioning. Context is important in under- standing symptoms. Both drugs and psychotherapy are used to treat anxiety disorders.
What are the characteristics of people with psychotic disorders?
Psychotic disorders involve personality disintegra- tion and loss of touch with reality. One major form is schizophrenia; hallucinations and delusions are the primary symptoms.
Schizophrenia is a severe thought disorder with an onset usually before age 45 , but it can begin in late life. People with early-onset schizophrenia often improve over time as neurotransmitters become more balanced. Treatment usually consists of drugs; psychotherapy alone is not often effective.
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308 CHAPTER 10
What are the major issues involved with substance abuse?
With the exception of alcohol, the substances most likely to be abused vary with age; younger adults are more likely to abuse illicit substances, whereas older adults are more likely to abuse prescription and over-the-counter medications.
Alcohol dependency declines with age from its highest rates in young adulthood. Older adults take longer to withdraw, but similar therapies are effective in all age groups.
Review Questions 10.1 Mental Health and the Adult Life Course
How do definitions of mental health vary with age?
What are the implications of adopting a multidi- mensional model for interpreting and diagnosing mental disorders?
Why are ethnicity and gender important consider- ations in understanding mental health?
10.2 Developmental Issues in Assessment and Therapy
What is multidimensional assessment? How is it done?
What major factors affect the accuracy of clinical assessment?
How do the developmental forces influence assessment?
What are the main developmental issues clinicians must consider in selecting therapy?
10.3 The Big Three: Depression, Delirium, and Dementia
How does the rate of depression vary with age, gender, and ethnicity?
What symptoms are associated with depression? How do they vary with age?
What biological causes of depression have been proposed? How are they related to therapy?
How is loss associated with depression? What treatments for depression have been devel-
oped? How well do they work with older adults?
What is delirium? What causes it? Why are older adults more susceptible?
What is Alzheimer’s disease? How is it diagnosed? What causes Alzheimer’s disease? What interven-
tions are available? What other types of dementia have been identi-
fied? What are their characteristics?
10.4 Other Mental Disorders and Concerns What symptoms are associated with anxiety disor-
ders? How are anxiety disorders treated? What are psychoses? What are their major symp-
toms? What treatments are most effective for schizophrenia?
What developmental differences have been noted regarding substance abuse? How is alcohol depen- dency defined
INTEGRATING CONCEPTS IN DEVELOPMENT Why is it so difficult to diagnose mental disorders in
older adults? What concepts from Chapters 3 and 4 provide major reasons?
Why do you think people with Alzheimer’s disease might experience hallucinations and delusions?
Why is there a connection between depression and dementia?
What would studying people with Alzheimer’s dis- ease tell us about normal memory changes with age?
KEY TERMS Alzheimer’s disease An irreversible form of dementia characterized by progressive declines in cognitive and bodily functions, eventually resulting in death; it accounts for about 70 % of all cases of dementia.
Autosomal dominant inheritance patterns A genetic inheritance pattern that requires only one gene from either one’s mother or father in order to cause a trait or condition to develop.
behavior therapy A type of psychotherapy that focuses on and attempts to alter current behavior. Underlying causes of the problem may not be addressed.
beta-amyloid A type of protein involved in the formation of neuritic plaques both in normal aging and in Alzheimer’s disease.
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CLINICAL ASSESSMENT, MENTAL HEALTH, AND MENTAL DISORDERS 309
beta-amyloid cascade hypothesis The process that beta-amyloid deposits create neuritic plaques, that in turn lead to neurofibrillary tangles, that cause neuronal death and, when this occurs severely enough, Alzheimer’s disease.
cognitive behavior therapy A type of psychotherapy aimed at altering the way people think as a cure for some forms of psychopathology, especially depression.
delirium A disorder characterized by a disturbance of consciousness and a change in cognition that develop over a short period of time.
dementia A family of diseases characterized by cognitive decline. Alzheimer’s disease is the most common form.
dysphoria Feeling down or blue, marked by extreme sadness; the major symptom of depression.
mental status exam A short screening test that assesses mental competence, usually used as a brief indicator of dementia or other serious cognitive impairment.
spaced retrieval A behavioral, implicit-internal memory intervention used in early- and middle-stage dementia.
sundowning The phenomenon when people with Alzheimer’s disease show an increase in symptoms later in the day.
vascular dementia A form of dementia caused by a series of small strokes.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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Relationships
11.1 RELATIONSHIP TYPES AND ISSUES Friendships • Love Relationships • How Do We Know?: Patterns and Universals of Romantic Attachment Around the World • Violence in Relationships
11.2 LIFESTYLES AND LOVE RELATIONSHIPS Singlehood • Cohabitation • Gay and Lesbian Couples • Marriage • Divorce • Current Controversies: Do Marriage Education Programs Work? • Remarriage • Widowhood
11.3 FAMILY DYNAMICS AND THE LIFE COURSE The Parental Role • Midlife Issues: Adult Children and Caring for Aging Parents • Discovering Development: Caring for Aging Parents • Grandparenthood
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 11
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RELATIONSHIPS 311
11.1 Relationship Types and Issues LEARNING OBJECTIVES
What role do friends play across adulthood? What characterizes love relationships? How do
they vary across cultures? What are abusive relationships? What
characterizes elder abuse, neglect, and exploitation?
J amal and Kahlid have known each other all their lives. They grew up together in New York, attended the same schools, and even married sisters. Their business careers took them in different directions, but they and their fami- lies always got together on major holidays. Now as older men, they feel a special bond; many of their other friends have died.
Having other people in our lives we can count on is essential to our well-being. Just imagine how dif- ficult life would be if you were totally alone, without even a Facebook “friend” to communicate with. In this section, we consider the different types of relationships we have with other people, and learn how these rela- tionships help—and sometimes hurt us.
Friendships Jamal and Kahlid remind us some of the most impor- tant people in our lives are our friends. They are often the people to whom we are closest, and are there when we need someone to lean on.
What is an adult friend? Someone who is there when you need to share? Someone that’s not afraid to tell you the truth? Someone you have fun with? Friends, of course, are all of these and more. Research- ers define friendship as a mutual relationship in which those involved influence one another’s behaviors and beliefs, and define friendship quality as the satisfaction derived from the relationship (Blieszner & Roberto, 2012; Flynn, 2007).
Friends are a source of support throughout adult- hood (Arnett, 2007). Friendships are predominantly based on feelings and grounded in reciprocity and choice. Friendships are different from love relation- ships mainly because friendships are less emotion- ally intense and usually do not involve sex (Blieszner & Roberto, 2012). Having good friendships boosts
Barack and Michelle Obama are, by nearly every measure, a successful couple. Elected president at age 47 , Barack Obama is supported by his wife, Michelle, who herself is a successful professional. Their relation- ship provides them the grounding necessary to support each other. Neither of them could have achieved what they have without the help of many friends.
Barack’s and Michelle’s experiences reflect some of the key aspects of relationships we exam- ine in this chapter. First, we consider friendships and love relationships and how they change across adulthood. Because love relationships usually involve a couple, we will explore how two people find each other and marry and how marriages develop. We also consider singlehood, divorce, remarriage, and widowhood. Finally, we take up some of the important roles associated with personal relationships, including parenting, family roles, and grandparenting.
Ro n
Sa ch
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ol /G
et ty
Im ag
es
Presidsiddent Baraca k andd MicMichellee ObaObamama
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312 CHAPTER 11
self-esteem (Bagwell et al., 2005) and happiness (Demir, 2010). Friendships also help us become social- ized into new roles throughout adulthood.
Friendship in Adulthood. From a developmental perspective, adult friendships can be viewed as having identifiable stages (Levinger, 1980, 1983): Acquain- tanceship, Buildup, Continuation, Deterioration, and Ending. This ABCDE model describes the stages of friendships and how they change. Whether a friendship develops from Acquaintanceship to Buildup depends on where the individuals fall on several dimensions, such as the basis of the attraction, what each person knows about the other, how good the communication is between the partners, the perceived importance of the friendship, and so on. Although many friendships reach the Deterioration stage, whether a friendship ultimately ends depends heavily on the availability of alternative relationships. If potential friends appear, old friendships may end; if not, they may continue even though they are no longer considered important by either person.
Longitudinal research shows how friendships change across adulthood, some in ways that are pre- dictable and others not. As you probably have expe- rienced, life transitions (e.g., going away to college, getting married) usually result in fewer friends and less contact with the friends you keep (Blieszner & Roberto, 2012). People tend to have more friends and acquaintances during young adulthood than at any subsequent period (Sherman, de Vries, & Lansford, 2000). Friendships are important throughout adult- hood, in part because a person’s life satisfaction is strongly related to the quantity and quality of contacts with friends. College students with strong friendship networks adjust better to stressful life events whether those networks are face-to-face (e.g., Brissette, Scheier, & Carver, 2002) or through online social networks (DeAndrea, Ellison, LaRose, Steinfield, & Fiore, 2012).
The importance of maintaining contacts with friends cuts across ethnic lines as well. People who have friendships that cross ethnic groups have more positive attitudes toward people with different back- grounds (Aberson, Shoemaker, & Tomolillo, 2004). Thus, regardless of one’s background, friendships play a major role in determining how much we enjoy life.
The quality and purpose of late-life friendships are particularly important (Bromell & Cagney, in
press; Schulz & Morycz, 2013). Having friends pro- vides a buffer against the losses of roles and status that accompany old age, such as retirement or the death of a loved one, and can increase people’s happiness and self-esteem (Schulz & Morycz, 2013). People who live alone especially benefit from friends in the neighbor- hood (Bromell & Cagney, in press).
Why does friendship have such positive ben- efits for us? Although scientists do not know for cer- tain, they are gaining insights through neuroscience research. Coan and colleagues (Beckes & Coan, 2013a; Beckes, Coan, & Hasselmo, in press; Coan, 2008) have found being faced with threatening situations results in different brain processing if faced alone or with a close friend. Specifically, neuroimaging showed defini- tively the parts of the brain that respond to threat oper- ate when facing threat alone but do not when facing the same threat with a close friend. It is becoming clear a close friendship literally changes the way the brain functions, resulting in our perception of feeling safer and the trials we face are more manageable with friends than without them.
Patterns of friendship among older adults tend to mirror those in young adulthood (Rawlins, 2004). Older women have more numerous and intimate friendships than older men do. Men’s friendships, like women’s, evolve over time and become important sources of support in late life (Adams & Ueno, 2006).
Three broad themes characterize both traditional (e.g., face-to-face) and new forms (e.g., online) of adult friendships (de Vries, 1996; Ridings & Gefen, 2004):
The affective or emotional basis of friendship refers to self-disclosure and expressions of inti- macy, appreciation, affection, and support, and all are based on trust, loyalty, and commitment.
The shared or communal nature of friendship reflects how friends participate in or support activities of mutual interest.
The sociability and compatibility dimension rep- resents how our friends keep us entertained and are sources of amusement, fun, and recreation.
In the case of online friendships (e.g., through social media), trust develops on the basis of four sources: (1) reputation; (2) performance, or what users do online; (3) precommitment, through
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personal self-disclosure; and (4) situational factors, especially the premium placed on intimacy and the relationship (Henderson & Gilding, 2004). Not sur- prisingly, online social network friendships develop much like face-to-face ones in that the more time people spend online with friends the more likely they are to self-disclose (Chang & Hsiao, in press). Online environments are more conducive to people who are lonely (e.g., live alone), which makes them poten- tially important for older adults (Cotton, Anderson, & McCullough, 2013).
A special type of friendship exists with one’s sib- lings, who are the friends people typically have the lon- gest and that share the closest bonds; the importance of these relationships varies with age (Carr & Moorman, 2011; Moorman & Greenfield, 2010). The centrality of siblings in later life depends on several things, such as proximity, health, and degree of relatedness (full, step-, or half-siblings). No clear pattern of emotional close- ness emerges when viewing sibling relationships on the basis of gender.
Developmental Aspects of Friendships and Socio- emotional Selectivity. Why are friends important to older adults? Some researchers believe one reason may be older adults’ not wanting to become burdens to their families (Blieszner & Roberto, 2012; Moorman & Greenfield, 2010). As a result, friends help each other foster independence.
Older adults tend to have fewer relationships with people in general and develop fewer new relationships than people do in midlife and particularly in young adulthood (Carr & Moorman, 2011). Carstensen and colleagues (Carstensen, 2006; Charles & Carstensen, 2010; Reed & Carstensen, 2012) have shown the changes in social behavior seen in late life reflect a more complicated and important process. They pro- pose a life-span theory of socioemotional selectivity , that argues social contact is motivated by a variety of goals, including information seeking, self-concept, and emotional regulation.
Each of these goals is differentially salient at differ- ent points of the adult life span and results in different social behaviors. When information seeking is the goal, such as when a person is exploring the world trying to figure out how he or she fits, what others are like, and so forth, meeting many new people is an essential part
of the process. However, when emotional regulation is the goal, people become highly selective in their choice of social partners and nearly always prefer people who are familiar to them.
Carstensen and colleagues believe information seeking is the predominant goal for young adults, emo- tional regulation is the major goal for older people, and both goals are in balance in midlife. Their research supports this view; people become increasingly selec- tive in whom they choose to have contact with. Addi- tionally, Magai (2008) summarizes several approaches to emotional development across adulthood and con- cludes people orient more toward emotional aspects of life and personal relationships as they grow older and emotional expression and experience become more complex and nuanced. Carstensen’s theory provides a complete explanation of why older adults tend not to replace, to any great extent, the relationships they lose: Older adults are more selective and have fewer oppor- tunities to make new friends, especially in view of the emotional bonds involved in friendships.
Men’s, Women’s, and Cross-Sex Friendships. Men’s and women’s friendships tend to differ in adulthood, reflecting continuity in the learned behaviors from childhood (Levine, 2009). Women base their friend- ships on more intimate and emotional sharing and use friendship as a means to confide in others. For women, getting together with friends often takes the form of getting together to discuss personal matters. Confiding in others is a basis of women’s friendships. In contrast, men base friendships on shared activities or interests.
What about friendships between men and women? These friendships have a beneficial effect, especially for men (Piquet, 2007). Cross-sex friend- ships help men have lower levels of dating anxiety and higher capacity for intimacy. These patterns hold across ethnic groups, too. Cross-sex friendships can also prove troublesome because of misperceptions. Some research shows men overestimate and women underestimate their friends’ sexual interest in them (Koenig, Kirkpatrick, & Ketelaar, 2007). Maintain- ing cross-sex friendships once individuals enter into exclusive dating relationships, marriage, or commit- ted relationships is difficult, and often results in one partner feeling jealous (Williams, 2005).
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314 CHAPTER 11
Love Relationships Love is one of those things everybody feels but nobody can define completely. (Test yourself: Can you explain fully what you mean when you look at someone spe- cial and say, “I love you”?) One way researchers try to understand love is to think about what components are essential. In an interesting series of studies, Stern- berg (2006) found love has three basic components: (1) passion , an intense physiological desire for some- one; (2) intimacy , the feeling that you can share all your thoughts and actions with another; and (3) com- mitment , the willingness to stay with a person through good and bad times. Ideally, a true love relationship has all three components; when couples have equiva- lent amounts of love and types of love, they tend to be happier; the balance among these components often shifts as time passes.
Love Through Adulthood. The different combina- tions of love help us understand how relationships develop (Sternberg, 2006). Research shows the devel- opment of romantic relationships is a complex pro- cess influenced by relationships in childhood and adolescence (Collins & van Dulmen, 2006). Early in a romantic relationship, passion is usually high whereas intimacy and commitment tend to be low. This is infat- uation: an intense, physically based relationship when the two people have a high risk of misunderstanding and jealousy. Indeed, it is sometimes difficult to estab- lish the boundaries between casual sex and hook-ups and dating in young adulthood (Giordano et al., 2012).
Infatuation is short-lived. As passion fades, either a relationship acquires emotional intimacy or it is likely to end. Trust, honesty, openness, and acceptance must be a part of any strong relationship; when they are present, romantic love develops.
This pattern is a good thing. Research shows peo- ple who select a partner for a more permanent relation- ship (e.g., marriage) during the height of infatuation are more likely to divorce (Hansen, 2006). If the couple spends more time and works at their relationship, they may become committed to each other.
Lemieux and Hale (2002) demonstrated these developmental trends hold in romantically involved couples between 17 and 75 years of age. As the length of the relationship increases, intimacy and passion decrease but commitment increases.
Falling in Love. In his book The Prophet , Kahlil Gibran points out love is two-sided: Just as it can give you great ecstasy, so can it cause you great pain. Yet most of us are willing to take the risk. As you may have experienced, taking the risk is fun (at times) and dif- ficult (at other times).
The best explanation of the process is the theory of assortative mating , that states people find part- ners based on their similarity to each other. Assorta- tive mating occurs along many dimensions, including education, religious beliefs, physical traits, age, socio- economic status, intelligence, and political ideology, among others (Blossfeld, 2009). Such nonrandom mat- ing occurs most often in Western societies that allow people to have more control over their own dating and pairing behaviors. Common activities are one basis for identifying potential mates, except, that is, in speed dating situations. In that case, it comes down to physi- cal attractiveness (Luo & Zhang, 2009).
People meet people in all sorts of places. Does the location where people meet influence the likelihood they will “click” on particular dimensions and form a couple? Kalmijn and Flap (2001) found that it does. Using data from more than 1,500 couples, they found meeting at school was most likely to result in the most forms of homogamy —the degree to which people are similar. Not surprisingly, the pool of available people to meet is strongly shaped by the opportunities avail- able, that in turn constrain the type of people one is likely to meet.
Speed dating provides a way to meet several people in a short period of time. Speed dating is prac- ticed most by young adults (Fein & Schneider, 2013; Whitty & Buchanan, 2009). The rules governing
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partner selection during a speed dating session seem quite similar to traditional dating: physically attractive people, outgoing and self-assured people, and moder- ately self-focused people are selected more often and their dates are rated as smoother (Eastwick, Saigal, & Finkel, 2010).
The popularity of online dating means an increas- ing number of people meet this way (Fein & Schnei- der, 2013; Whitty & Buchanan, 2009). Surveys indicate nearly 1 in every 5 couples in the United States meet online (compared with 1 in 10 in Australia, and 1 in 20 in Spain and the United Kingdom; Dutton et al., 2009). Emerging research indicates virtual dating sites offer both problems and possibilities, especially in terms of the accuracy of personal descriptions. Like in the offline world, physical attractiveness strongly influ- ences initial selections online (Sritharan et al., 2010). Many couples have met and formed committed rela- tionships via online sites (Mazzarella, 2007).
One increasing trend among emerging adults is the hookup culture of casual sex, often without even
knowing the name of one’s sexual partner (Garcia, Reiber, Massey, & Merriwether, 2013). Research indi- cates both men and women are interested in having hookup sex, but also prefer a more romantic relation- ship over the long run. However, the perception there are no strings attached to hookup sex appear wrong, as nearly three-fourths of both men and women eventually expressed some level of regret at having hookup sex.
How does couple-forming behavior compare cross-culturally? As described in the Spotlight on Research feature, Schmitt and his team of colleagues (2004) studied 62 cultural regions. They showed secure romantic attachment was the norm in nearly 80 % of cultures and “preoccupied” romantic attach- ment was particularly common in East Asian cultures. In general, multicultural studies show there are global patterns in mate selection and romantic relationships. The romantic attachment profiles of individual nations were correlated with sociocultural indicators in ways that supported evolutionary theories of romantic attachment and basic human mating strategies.
HOW DO WE KNOW?: PATTERNS AND UNIVERSALS OF ROMANTIC ATTACHMENT AROUND THE WORLD Who were the investigators and what was the aim of the study? One’s attachment style may have a major influence on how one forms romantic relationships. In order to test this hypothesis, David Schmitt (2004) assembled a large international team of researchers.
How did the investigators measure the topic of interest? Great care was taken to ensure equivalent translation of the survey across the 62 cultural regions included. The survey was a two-dimension four-category measure of adult romantic attachment (the Relationship Questionnaire) that measured models of self and others relative to each other: secure romantic attachment (high scores indicate positive models of self and others), dismissing romantic attachment (high scores indicate a positive model of self and a negative model of others), preoccupied romantic attachment (high scores indicate a negative model of self and a positive model of others), and fearful romantic attachment (high scores indicate negative models of self and others). An overall score of model of self is computed by adding together the secure and dismissing scores and subtracting the com- bination of preoccupied and fearful scores. The overall
model of others score is computed by adding together the secure and preoccupied scores and subtracting the combination of dismissing and fearful scores.
Additionally, there were measures of self-esteem, personality traits, and sociocultural correlates of roman- tic attachment (e.g., fertility rate, national profiles of individualism versus collectivism).
Who were the participants in the study? A total of 17,804 people ( 7,432 men and 10,372 women) from 62 cultural regions around the world took part in the study. Such large and diverse samples are unusual in developmental research.
What was the design of the study? Data for this cross-sectional, nonexperimental study were gath- ered by research teams in each country. The principal researchers asked the research collaborators to admin- ister a nine-page survey to the participants that took 20 minutes to complete.
Were there ethical concerns with the study? Because the study involved volunteers, there were no ethical concerns. However, ensuring all participants’ rights were protected was a challenge because of the number of countries and cultures involved.
What were the results? The researchers first dem- onstrated the model of self and others measures were valid across cultural regions, that provided general support for the independence of measures (i.e., they
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316 CHAPTER 11
Culture is a powerful force in shaping mate selec- tion choices. Specifically, across 48 different cultures globally, people from cultures that have good health care, education, and resources, and permit young adults to choose their own mates tend to develop more secure romantic attachments than do people from cultures without these characteristics (Schmitt et al., 2009).
Cultural norms are sometimes highly resistant to change. Loyalty of the individual to the family is an important value in India, so despite many changes in mate selection, about 95 % of marriages in India are carefully arranged to ensure an appropriate mate is selected (Dommaraju, 2010). Similarly, Islamic soci- eties use matchmaking as a way to preserve family consistency and continuity and ensure couples follow the prohibition on premarital relationships between men and women (Adler, 2001). Matchmaking in these societies occurs both through family connections and
personal advertisements in newspapers. To keep up with the Internet age, Muslim matchmaking has gone online too (Lo & Aziz, 2009).
Violence in Relationships Up to this point, we have been considering relation- ships that are healthy and positive. Sadly, this is not always the case. Sometimes relationships become violent; one person becomes aggressive toward the partner, cre- ating an abusive relationship . Such relationships have received increasing attention since the early 1980s, when the U.S. criminal justice system ruled that, under some circumstances, abusive relationships can be used as an explanation for one’s behavior (Walker, 1984). For example, battered woman syndrome occurs when a woman believes she cannot leave the abusive situation and may even go so far as to kill her abuser.
Being female, Latina, African American, having an atypical family structure (something other than two
measure different things). Specific analyses showed 79 % of the cultural groups studied demonstrated secure romantic attachments, but North American cultures tended to be dismissive and East Asian cultures tended to be high on preoccupied romantic attachment. These patterns are shown in Figure 11.1 . Note all the cultural regions except East Asia showed the pattern of model of self scores higher than model of others scores.
What did the investigators conclude? Overall, Schmitt and colleagues concluded although the same attachment pattern holds across most cultures, no one pattern holds across all of them. East Asian cultures in particular tend to fit a pattern in which people report others do not get as emotionally close as the respon- dent would like, and respondents find it difficult to trust others or to depend on them.
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Figure 11.1 In research across 10 global regions, note that only in East Asian cultures were the “model of others” scores higher than the “model of self” scores. Source: Data from Schmitt et al. (2004).
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biological parents), having more romantic partners, early onset of sexual activity, and being a victim of child abuse predicts victimization. Although overall national rates of sexual assault have declined more than 60 % since the early 1990s, acquaintance rape or date rape is still a major problem; college women are 4 times more likely to be the victim of sexual assault than are women in other age groups (Rape, Abuse, and Incest National Network, 2013), with 40 % experiencing abuse in a dat- ing relationship (DatingAbuseStopsHere.com, 2013).
What range of aggressive behaviors occurs in abu- sive relationships? What causes such abuse? Based on considerable research on abusive partners, O’Leary (1993) argues there is a continuum of aggressive behaviors toward a partner, and progresses as follows: verbally aggressive behaviors, physically aggressive behaviors, severe physically aggressive behaviors, and murder (see Table 11.1 ). The causes of the abuse also vary with the type of abusive behavior being expressed.
Two points about the continuum should be noted. First, there may be fundamental differences in the types of aggression independent of level of severity. Overall, each year about 5 million women and 3 million men experience partner-related physical assaults and rape in the United States (Centers for Disease Control and Prevention, 2012h); worldwide, between 10 % and 69 % of women report being physically assaulted or raped (World Health Organization, 2002).
The second point, depicted in the table, is the sus- pected underlying causes of aggressive behaviors differ as the type of aggressive behaviors change (O’Leary, 1993). Although anger and hostility in the perpetra- tor are associated with various forms of physical abuse, the exact nature of this relationship remains elusive ( Norlander & Eckhardt, 2005).
Men are also the victims of violence from inti- mate partners, though at a rate about one-third that of women (Conradi & Geffner, 2009). Studies in
Verbal aggression Physical aggression Severe aggression Murder
Insults Yelling Name-calling
Contributing factors: job stresses and unemployment
Note: Need to control and other variables on the left are associated with all forms of aggression; acceptance of violence and other variables in the middle are associated with physical aggression, severe aggression, and murder. Personality disorders and the variables on the right are associated with severe aggression and murder.
* More relevant for males than for females.
Causes Need to control* Misuse of power* Jealousy* Marital discord
Pushing Slapping Shoving
Accept violence as a means of control Modeling of physical aggression Abused as a child Aggressive personality styles Alcohol abuse
Beating Punching Hitting with object
Personality disorders Emotional lability Poor self-esteem
Table 11.1
Continuum of progressive behaviors in abusive relationships
Source: O’Leary, K. D. (1993). Through a psychological lens: Personality traits, personality disorders, and levels of violence. In R. J. Gelles & D. R. Loseke (Eds.), Current Controversies on Family Violence (pp. 7–30). Copyright © 1993 by Sage Publications. Reprinted by permission of the publisher.
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318 CHAPTER 11
New Zealand and the United States revealed both men and women showed similar patterns of holding tradi- tional gendered beliefs, and lacking communication and anger management skills; however, intervention programs tend to focus on male perpetrators (Hines & Douglas, 2009; Robertson & Murachver, 2007). Research in Canada showed heterosexual couples reported more instances of violence than did gay or lesbian couples (Barrett & St. Pierre, 2013).
Culture is also an important contextual factor in understanding partner abuse. In particular, violence against women worldwide reflects cultural traditions, beliefs, and values of patriarchal societies; this can be seen in the commonplace violent practices against women that include sexual slavery, female genital cutting, intimate partner violence, and honor killing (Parrot & Cummings, 2006).
Additionally, international data indicate rates of abuse are higher in cultures that emphasize female purity, male status, and family honor. A common cause of women’s murders in Arab countries is brothers or other male relatives killing the victim because she violated the family’s honor (Kulwicki, 2002). Intimate partner violence is prevalent in China ( 43 % lifetime risk in one study) and has strong associations with male patriarchal values and conflict resolutions (Xu et al., 2005).
Alarmed by the seriousness of abuse, many com- munities established shelters for battered women and their children as well as programs that treat abusive men. However, the legal system in many localities is still not set up to deal with domestic violence; women in some locations cannot sue their husbands for assault, and restraining orders all too often offer little real pro- tection from additional violence. Much remains to be done to protect women and their children from the fear and the reality of continued abuse.
Elder Abuse, Neglect, and Exploitation. Although elder abuse, neglect, and exploitation are difficult to define precisely, several categories are commonly used (National Center on Elder Abuse, 2013):
Physical abuse: the use of physical force that may result in bodily injury, physical pain, or impairment
Sexual abuse: nonconsensual sexual contact of any kind
Emotional or psychological abuse: infliction of anguish, pain, or distress
Financial or material exploitation: the illegal or improper use of an older adult’s funds, property, or assets
Abandonment: the desertion of an older adult by an individual who had physical custody or other- wise assumed responsibility for providing care for the older adult
Neglect: refusal or failure to fulfill any part of a person’s obligation or duties to an older adult
Self-neglect: the behaviors of an older person that threaten his or her own health or safety, exclud- ing those conscious and voluntary decisions by a mentally competent and healthy adult
Researchers estimate perhaps 1 in 4 vulnerable older adults are at risk for some type of abuse, neglect, or exploitation (Cooper, Selwood, & Livingston, 2008; Nerenberg, 2010). Unfortunately, only a small propor- tion of these cases are actually reported to authorities; of the ones that are, neglect is the most common type. If you suspect an older adult is a victim of elder abuse, neglect, or exploitation, the best thing to do is to contact your local adult protective services office and report it.
ADULT DEVELOPMENT IN ACTION As a couples therapist, what do you need to know about global friendship and mating patterns?
11.2 Lifestyles and Love Relationships LEARNING OBJECTIVES
What are the challenges and advantages of being single?
Why do people cohabit? What are gay male and lesbian relationships like? What is marriage like across adulthood? Why do people divorce? Why do people remarry? What are the experiences of widows and
widowers?
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B obbie and Jack were high school sweethearts who married a few years after World War II. Despite many trials in their relationship, they have remained firmly committed to each other for more than 60 years. Not only are they still in love, but they are best friends. In looking back, they note that once their children moved away they grew closer again. Bobbie and Jack wonder whether this is typical.
Bobbie and Jack show us forging relationships is only part of the picture in understanding how adults live their lives with other people. For most, one relationship becomes special and results in commitment, typically through marriage. Putting relationships in context is the goal of this section as we explore the major lifestyles of adults. First, we consider people who never get mar- ried. Next, we look at those who cohabit and those who are in same-sex relationships. We also consider couples who get married and those who divorce and remarry. Finally, we discuss people who are widowed.
Singlehood Many men and women are single—defined as not liv- ing with an intimate partner—at more than one point in adulthood. In this section, we focus most on young adult singles; elsewhere we return to singlehood in the context of divorce or the death of a spouse/partner.
What’s it like to be a single young adult in the United States? It’s tougher than you might think. DePaulo (2006) points out numerous stereotypes and biases against single people. Her research found young adults characterized married people as caring, kind, and giving about 50 % of the time compared with only 2 % for single people. DePaulo also found rental agents preferred married couples 60 % of the time (Morris, Sinclair, & DePaulo, 2007).
Many women and men remain single as young adults to focus on establishing their careers rather than marriage or relationships that most do later. Others report they simply did not meet “the right person” or prefer singlehood (Ibrahim & Hassan, 2009). However, the pressure to marry is especially strong for women.
Men remain single longer in young adulthood because they marry at a later age than women (U.S. Census Bureau, 2010a). Fewer men than women remain unmarried throughout adulthood, though, mainly because men find partners more easily as they select from a larger age range of unmarried women.
Ethnic differences in singlehood reflect differences in age at marriage as well as social factors. Nearly twice as many African Americans are single during young adulthood as European Americans, and more are choosing to remain so (U.S. Census Bureau, 2010b). Singlehood is also increasing among Latinos, in part because the average age of Latinos in the United States is lower than other ethnic groups and in part because of poor economic opportunities for many Latinos (Lamanna & Riedmann, 2003).
Globally, the meanings and implications of remain- ing single are often tied to strongly held cultural and religious beliefs. Muslim women who remain single in Malaysia speak in terms of jodoh (the soul mate one finds through fate at a time appointed by God) as a rea- son; they believe God simply has not decided to have them meet their mate at this time (Ibrahim & Hassan, 2009). But because the role of Malaysian women is to marry, they also understand their marginalized posi- tion in society through their singlehood. In Southeast Asia, the number of single adults has increased steadily as education levels rose over the past several decades (Hull, 2009). However, family systems in these cultures have not yet adapted to these changing lifestyle pat- terns (Jones, 2010).
An important distinction is between adults who are temporarily single (i.e., those who are single only until they find a suitable marriage partner) and those who choose to remain single. For most singles, the decision to never marry is a gradual one. This transi- tion is represented by a change in self-attributed status that occurs over time and is associated with a cul- tural timetable for marriage. It marks the experience of “becoming single” that occurs when an individual identifies more with singlehood than with marriage (Davies, 2003).
Cohabitation Being unmarried does not necessarily mean living alone. People in committed, intimate, sexual rela- tionships but who are not married may decide living together, or cohabitation , provides a way to share daily life. Cohabitation is becoming an increasingly popular lifestyle choice in the United States as well as in Canada, Europe, Australia, and elsewhere. Cohabitation in the United States has increased 10 - fold over the past three decades: from 523,000
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in 1970 to 5.5 million in 2002, the most recent year extensive data were collected (Goodwin, Mosher, & Chandra, 2010). People with lower educational levels cohabit more, and do so in more relationships, than individuals with higher educational levels. European American, African American, and Latino men and women cohabit at about the same rates, other factors being equal.
Couples cohabit for three main reasons, most often in connection with testing their relationship in the context of potential marriage, but also for conve- nience and as an alternative to marriage (Rhoades, Stanley, & Markman, 2009).
The global picture differs by culture (Popenoe, 2009; Therborn, 2010). In most European, South American, and Caribbean countries, cohabitation is a common alternative to marriage for young adults. Cohabitation is extremely common in the Nether- lands, Norway, and Sweden, where this lifestyle is part of the culture; 99 % of married couples in Sweden lived together before they married and nearly one in four couples are not legally married. Decisions to marry in these countries are typically made to legalize the relationship after children are born—in contrast to Americans, who marry to confirm their love and com- mitment to each other.
Interestingly, having cohabitated does not seem to make marriages any better; in fact, it may do more harm than good, resulting in lower quality marriages (Tach & Halpern-Meekin, 2009). These findings reflect two underlying issues: couples who have chil- dren while cohabiting, especially for European Ameri- can women (as compared with African American and Latina women; Tach & Halpern-Meekin, 2009), and couples who are using cohabitation to test their rela- tionship (Rhoades et al., 2009) are most likely to report subsequent problems.
Longitudinal studies find few differences in cou- ples’ behavior after living together for many years regardless of whether they married without cohabiting, cohabited then married, or simply cohabited (Stafford, Kline, & Rankin, 2004). Additionally, many coun- tries extend the same rights and benefits to cohabit- ing couples as they do to married couples, and have done so for many years. Argentina provides pension rights to cohabiting partners, Canada extends insur- ance benefits, and Australia has laws governing the
disposition of property when cohabiting couples sever their relationship (Neft & Levine, 1997).
Gay and Lesbian Couples Less is known about the developmental course of gay and lesbian relationships than heterosexual relation- ships (Rothblum, 2009). What is it like to be in a gay or lesbian relationship?
For the most part, the relationships of gay and lesbian couples have many similarities to those of het- erosexual couples (Kurdek, 2004). Most gay and les- bian couples are in dual-earner relationships, much like the majority of married heterosexual couples, and are likely to share household chores. However, gay and lesbian couples differ from heterosexual couples in the degree to which both partners are similar on demo- graphic characteristics such as race, age, and educa- tion; gay and lesbian couples tend to be more dissimilar (Schwartz & Graf, 2009).
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RELATIONSHIPS 321
Gay men, like heterosexual men, separate love and sex and have more short-term relationships (Missildine et al., 2005); both lesbian and heterosexual women are more likely to connect sex and emotional intimacy in fewer, longer-lasting relationships. Lesbians tend to make a commitment and cohabit faster than hetero- sexual couples (Ganiron, 2007).
Gay and lesbian couples report receiving less support from family members than either married or cohabiting couples (Rothblum, 2009). At a soci- etal level, marriage or civil unions between same-sex couples remains highly controversial in America, with several states passing constitutional amend- ments or statutes defining marriage as between a man and a woman. The lack of legal recognition for gay and lesbian relationships in the United States also means certain rights and privileges, such as mar- riage, certain insurance benefits, and hospital visi- tation rights, are not always granted. Although the legal status of gay and lesbian couples is changing in more countries (most notably in Scandinavia), and a few states in the United States (including New York), most countries and states in the United States do not provide them with the same legal rights as married couples.
Marriage Most adults want their love relationships to result in marriage. However, U.S. residents are in less of a hurry to achieve this goal; the median age at first marriage for
adults in the United States has been rising for several decades. As shown in Figure 11.2 , between 1970 and 2010, the median age for first marriage rose roughly 4 years for both men and women (U.S. Census Bureau, 2013a).
What Is a Successful Marriage and What Predicts It? You undoubtedly know couples who appear to have a successful marriage. But what does that mean, really? Minnotte (2010) differentiates marital success , an umbrella term referring to any marital outcome (such as divorce rate), marital quality , a subjective evalua- tion of the couple’s relationship on a number of differ- ent dimensions, marital adjustment , the degree spouses accommodate each other over a certain period of time, and marital satisfaction , a global assessment of one’s marriage. Each of these provides a unique insight into the workings of a marriage.
Marriages, like other relationships, differ from one another, but some important predictors of future suc- cess can be identified. One key factor is age. In general, the younger the partners are, the lower the odds the marriage will last—especially when the people are in their teens or early 20s (U.S. Census Bureau, 2013b). Other reasons that increase or decrease the likelihood a marriage will last include financial security and preg- nancy at the time of the marriage.
A second important predictor of successful marriage is homogamy , or the similarity of values and interests a couple shares . As we saw in relation to choosing a mate,
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Figure 11.2 Note the median age at first marriage has been increasing for many years during the 20th and early 21st centuries. Source: U.S Census Bureau, Current Population Survey, Annual Social and Economic Supplements, 1947–2012. Data for years prior to 1947 are from decennial censuses. http://www.census.gov/hhes /families/data/marital.html
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322 CHAPTER 11
the extent the partners share similar age, values, goals, attitudes (especially the desire for children), socioeco- nomic status, certain behaviors (such as drinking alco- hol), and ethnic background increases the likelihood their relationship will succeed (Kippen, Chapman, & Yu, 2009).
A third factor in predicting marital success is a feeling the relationship is equal. According to exchange theory , marriage is based on each partner contribut- ing something to the relationship the other would be hard-pressed to provide. Satisfying and happy mar- riages result when both partners perceive there is a fair exchange, or equity, in all the dimensions of the relationship. Problems achieving equity arise because of the competing demands of work and family, an issue we take up again in Chapter 12 .
Cross-cultural research supports these factors. Couples in the United States and Iran (Asoodeh et al., 2010; Hall, 2006; McKenzie, 2003) say trust, consulting each other, honesty, making joint decisions, and com- mitment make the difference between a successful mar- riage and an unsuccessful marriage. Couples for whom religion is important also point to commonly held faith.
Do Married Couples Stay Happy? Few sights are happier than a couple on their wedding day. Newly- weds, like Kevin and Beth in the vignette, are at the peak of marital bliss. The beliefs people bring into a marriage influence how satisfied they will be as the marriage develops. But as you may have experienced, feelings change over time, sometimes getting better and stronger, sometimes not.
Research shows for most couples, overall marital satisfaction is highest at the beginning of the mar- riage, falls until the children begin leaving home, and rises again in later life; this pattern holds for both married and never-married cohabiting couples with children (see Figure 11.3 ; Hansen, Moum, & Shapiro, 2007). However, for some couples, satisfaction never rebounds and remains low; in essence, they have become emotionally divorced.
The pattern of a particular marriage over the years is determined by the nature of the dependence of each spouse on the other. When dependence is mutual and about equal and both people hold similar values that form the basis for their commitment to each other, the marriage is strong and close (Givertz, Segrin, & Hanzal, 2009). When the dependence of one partner is much higher than that of the other, however, the mar- riage is likely to be characterized by stress and conflict. Learning how to deal with these changes is the secret to long and happy marriages.
The fact marital satisfaction has a general down- ward trend but varies widely across couples led Karney and Bradbury (1995) to propose a vulner- ability–stress–adaptation model of marriage, depicted in Figure 11.4 . The vulnerability–stress–adaptation model sees marital quality as a dynamic process result- ing from the couple’s ability to handle stressful events in the context of their particular vulnerabilities and resources. As a couple’s ability to adapt to stressful situ- ations gets better over time, the quality of the marriage will probably improve. How well couples adapt to vari- ous stresses on the relationship determines whether
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Figure 11.3 Marital satisfaction is highest early on and in later life, dropping during the child-raising years. Source: Kail, R., & Cavanaugh, J.C. (2010). Human Development: A Life-Span View (5th ed., p. 412). Belmont, CA: Wadsworth.
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RELATIONSHIPS 323
the marriage continues or they get divorced. Let’s see how this works over time.
Setting the Stage: The Early Years of Marriage. Mar- riages are most intense in their early days. Discussing financial matters honestly is key since many newly married couples experience their first serious marital stresses around money issues (Parkman, 2007). How tough issues early in the marriage are handled sets the stage for the years ahead.
Early in a marriage, the couple must learn to adjust to the different perceptions and expectations each person has for the other. Research indicates men and women both recognize and admit when problems occur in their marriage (Moynehan & Adams, 2007). The couple must also learn to handle confrontation and resolve conflicts.
Early in a marriage, couples have global adora- tion for their spouse regarding the spouse’s qualities ( Karney, 2010; Neff & Karney, 2005). For wives, but not for husbands, more accurate specific perceptions of what their spouses are really like were associated with more supportive behaviors, feelings of control in the marriage, and a decreased risk of divorce. Couples who are happiest in the early stage of their marriage focus on the good aspects, not the annoyances; nit-picking and nagging do not bode well for long-term wedded bliss (Karney, 2010).
As time goes on and stresses increase, marital sat- isfaction declines (Lamanna & Riedmann, 2003). For most couples, the primary reason for this drop is hav- ing children (Jokela et al., 2009). It’s not just a matter of having a child. The temperament of the child matters, with fussier babies creating more marital problems
(Greving, 2007; Meijer & van den Wittenboer, 2007). Parenthood also means having substantially less time to devote to the marriage. Both African American and European American couples report an increase in con- flict after the birth of their first child (Crohan, 1996).
However, using the birth of a child as the explana- tion for the drop in marital satisfaction is much too simplistic, because child-free couples also experience a decline in marital satisfaction (Hansen et al., 2007). Longitudinal research indicates disillusionment—as demonstrated by a decline in feeling in love, in dem- onstrations of affection, and in the feeling that one’s spouse is responsive, as well as an increase in feelings of ambivalence—is a key predictor of marital dissatis- faction (Huston et al., 2001).
During the early years of their marriage, many couples may spend significant amounts of time apart, especially in the military (Fincham & Beach, 2010). Spouses that serve in combat areas on active duty assignment who suffer from post-traumatic stress dis- order (PTSD) are particularly vulnerable, since they are at greater risk for other spouse-directed aggression.
What the non-deployed spouse believes turns out to be important. If the non-deployed spouse believes the deployment will have negative effects on the marriage, then problems are much more likely. In contrast, if the non-deployed spouse believes such challenges make the relationship stronger, then they typically can do so (Renshaw, Rodrigues, & Jones, 2008). Research indicates the effects of deployment may be greater on wives than husbands; divorce rates for women service members who are deployed is higher than for their male counterparts (Karney & Crown, 2007).
Enduring vulnerabilities
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Figure 11.4 The vulnerability-stress- adaptation model shows how adapting to vulnerabilities and stress can result in either adaptation or dissolution of the marriage. Source: From “Keeping marriages healthy, and why it’s so difficult,” by B. R. Karney.
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324 CHAPTER 11
Marriage at Midlife. For most couples marital satis- faction improves after the children leave, a state called the empty nest. Midlife brings both challenges and opportunities for marriages (Karasu & Karasu, 2005). Some use the launching of children to rediscover each other, and marital satisfaction rebounds.
For some middle-aged couples, however, marital satisfaction continues to be low. They may have grown apart but continue to live together, a situation sometimes referred to as married singles (Lamanna & Riedmann, 2011). In essence, they become emotionally divorced and live more as housemates than as a married cou- ple; for these couples, spending more time together is not a welcome change. Research shows marital dis- satisfaction in midlife is a process that develops over a long period of time and is not spontaneous (Rokach, Cohen, & Dreman, 2004). Later in this chapter we explore the squeeze many midlife couples feel as they continue to provide support for (grown) children and assume more support and care providing responsi- bility for aging parents (Igarashi, Hooker, Coehlo, & Manoogian, 2013).
Older Couples. Marital satisfaction is fairly high in older couples, who describe their partner in more positive terms than do middle-aged married partners (Henry, Berg, Smith, & Florsheim, 2007). However, satisfaction in long-term marriages—that is, marriages of 40 years or more—is a complex issue. In general, marital satisfaction among older couples increases shortly after retirement but then decreases with health problems and advancing age, and is directly related to the level of perceived support each partner receives (Landis, Peter-Wright, Martin, & Bodenmann, 2013). The level of satisfaction in these marriages appears to be unrelated to the amount of past or present sexual interest or sexual activity, but it is positively related to the degree of social engagement such as interaction with friends (Bennett, 2005). In keeping with the mar- ried-singles concept, many older couples have simply developed detached, contented styles (Connidis, 2001; Lamanna & Riedmann, 2003).
Older married couples show several specific char- acteristics (O’Rourke & Cappeliez, 2005). Many older couples show a selective memory regarding the occur- rence of negative events and perceptions of their part- ner. Older couples have a reduced potential for marital
conflict and greater potential for pleasure, are more likely to be similar in terms of mental and physical health, and show fewer gender differences in sources of pleasure. In short, older married couples developed adaptive ways to avoid conflict and grown more alike. In general, marital satisfaction among older couples remains high until health problems begin to interfere with the relationship (Connidis, 2001).
Being married in late life has several benefits. A study of 9,333 European Americans, African Ameri- cans, and Latino Americans showed marriage helps people deal better with chronic illness, functional problems, and disabilities (Pienta, Hayward, & Jen- kins, 2000). Although the division of household chores becomes more egalitarian after the husband retires than it was when the husband was employed, irrespec- tive of whether the wife was working outside the home, women still do more than half of the work (Kulik, 2011).
Caring for a Spouse/Partner. When couples pledge their love to each other “in sickness and in health,” most envision the sickness part to be no worse than an illness lasting a few weeks. That may be the case for many couples, but for some the illness they experience severely tests their pledge.
Francine and Ron is one such couple. After 42 years of mainly good times together, Ron was diagnosed as having Alzheimer’s disease. When first contacted by staff at the local chapter of a caregiver support orga- nization, Francine had cared for Ron for 6 years. “At times it’s very hard, especially when he looks at me and doesn’t have any idea who I am. Imagine, after all these years, not to recognize me. But I love him, and I know that he would do the same for me. But, to be perfectly honest, we’re not the same couple we once were. We’re just not as close; I guess we really can’t be.”
Francine and Ron are typical of couples in which one partner cares for the other. Caring for a chroni- cally ill partner presents different challenges than car- ing for a chronically ill parent. The partner caregiver assumes the new role after decades of shared respon- sibilities. Often without warning, the division of labor that worked for years must be readjusted. Such change inevitably puts stress on the relationship (Haley, 2013). This is especially true when one’s spouse/partner has a debilitating chronic disease.
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Studies of spousal caregivers of persons with Alzheimer’s disease show marital satisfaction is much lower than for healthy couples (Cavanaugh & Kinney, 1994; Cohen, 2013; Haley, 2013). Spousal caregivers report a loss of companionship and intimacy over the course of caregiving, but also more rewards than adult child caregivers (Raschick & Ingersoll-Dayton, 2004). Marital satisfaction is an important predictor of spou- sal caregivers’ reports of depressive symptoms; the better the perceived quality of the marriage, the fewer symptoms caregivers report (Kinney et al., 1993), a finding that holds across European American and African American spousal caregivers (Parker, 2008).
Most partner caregivers adopt the caregiver role out of necessity. Although evidence about the mediat- ing role of caregivers’ appraisal of stressors is unclear, interventions that improve the functional level of the ill partner generally improve the caregiving partner’s situation (Van Den Wijngaart, Vernooij-Dassen, & Felling, 2007).
The importance of feeling competent as a part- ner caregiver fits with the docility component of the competence–environmental press model presented in Chapter 5 . Caregivers attempt to balance their per- ceived competence with the environmental demands of caregiving. Perceived competence allows them to be proactive rather than merely reactive (and doc- ile), that gives them a better chance to optimize their situation.
Even in the best of committed relationships, pro- viding full-time care for a partner is both stressful and rewarding in terms of the marital relationship (Baek,
2005; Chen, 2013; Haley, 2013). Coping with a wife who may not remember her husband’s name, acts strangely, and has a chronic and fatal disease presents serious challenges even to the happiest of couples. Yet even in that situation, the caregiving husband may experience no change in marital happiness despite the changes in his wife due to the disease.
Divorce Despite what couples pledge on their wedding day, many marriages do not last until death parts them; instead, marriages are dissolved through divorce. Most couples enter marriage with the idea their relation- ship will be permanent. Rather than growing together, though, many couples grow apart.
Who Gets Divorced and Why? Divorce in the United States is common, and the divorce rate is sub- stantially higher than in many other countries around the world; as you can see in Figure 11.5 , couples have roughly a 50–50 chance of remaining married for life (National Center for Health Statistics, 2013a). In con- trast, the ratio of divorces to marriages in Japan, Italy, and Spain are substantially lower as are rates in Africa and Asia (United Nations, 2008). However, divorce rates in nearly every developed country increased over the past several decades.
Of those marriages ending in divorce, African American and Asian American couples tended to be married longer at the time of divorce than European American couples, and ethnically mixed marriages are at greater risk (National Center for Health Statistics,
Figure 11.5 The United States has one of the highest divorce rates in the world. Source: U.S. Bureau of Labor Statistics, updated and revised from “Families and Work in Transition in 12 Countries, 1980–2001,” Monthly Labor Review, September 2003, with unpublished data. http://www.bls.gov/opub/mlr/2003/09 /art1full.pdf
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326 CHAPTER 11
2013a). People with higher levels of education tend to have lower rates of divorce (Cherlin, 2013).
Why people divorce has been the focus of much research. Although how couples manage conflict is important, there is more to it than that (Fincham, 2003).
Gottman and Levenson (2004) developed two models that predicted divorce early (within the first 7 years of marriage) and later (when the first child reaches age 14) with 93 % accuracy over the 14 - year period of their study. Negative emotions displayed dur- ing conflict between the couple predicted early divorce, but not later divorce. In general, this reflects a pattern of wife-demand–husband- withdraw ( Christensen, 1990) in which, during conflict, the wife places a demand on her husband, who then withdraws either emotionally or physically. In contrast, the lack of posi- tive emotions in a discussion of events-of-the-day and during conflict predicted later divorce, but not early divorce. An example would be a wife talking excitedly about a project she had just been given at work and her husband showing disinterest. Such “unrequited” inter- est and excitement in discussions likely carries over to the rest of the relationship.
Gottman’s research is important because it clearly shows how couples show emotion is critical to mari- tal success. Couples who divorce earlier typically do
so because of high levels of negative feelings such as contempt, criticism, defensiveness, and stonewalling experienced as a result of intense marital conflict. But for many couples, such intense conflict is generally absent. Although this makes it easier to stay in a marriage longer, the absence of positive emotions eventually takes its toll and results in later divorce. For a marriage to last, people need to be told they are loved and what they do and feel really matters to their partner.
But we must be cautious about applying Gott- man’s model to all married couples. Kim, Capaldi, and Crosby (2007) reported in lower-income high- risk couples, the variables Gottman says predict early divorce did not hold for that sample. For older, long- term married couples, the perception of the spouse’s support is the most important predictor of remaining married (Landis et al., 2013).
The high divorce rate in the United States and the reasons typically cited for getting divorced have sparked a controversial approach to keeping couples together, termed covenant marriage , that makes divorce much harder to obtain. Other proposals, such as the Healthy Marriage Initiative supported by the Heritage Founda- tion, raise similar issues. Will they work? That remains to be seen, as discussed in the Current Controversies feature.
CURRENT CONTROVERSIES: DO MARRIAGE EDUCATION PROGRAMS WORK? As a way to combat high divorce rates, the U.S. gov- ernment created the Healthy Marriage Initiative in the Department of Health and Human Services for promo- tion of healthy marriages and fatherhood. These in turn resulted in the National Healthy Marriage Center and the National Center for Family and Marriage Research. Research related to these initiatives focused on the pos- itive aspects of marriage and on the need to do a better job with marriage education (Fincham & Beach, 2010).
The Healthy Marriage Initiative is an example of marriage education , an approach based on the idea that the more couples are prepared for marriage, the bet- ter the relationship will survive over the long run. More than 40 states have initiated some type of education program. Do they work?
Most marriage education programs focus on com- munication between the couple. In addition to govern- ment or other publicly sponsored programs, several religious denominations have marriage education pro- grams; the Catholic’s Pre-Cana program is one example.
There are numerous challenges to more exten- sive community-based marriage education programs. In some cases the education programs were originally developed to address poverty (Administration for Chil- dren and Families, 2010). Many couples cohabit and are less likely to attend marriage education programs, even though there is little evidence that cohabitation improves communication skills between the couple (Fincham & Beach, 2010). As a result, versions of mar- riage education programs are being adapted for these situations. Additionally, programs timed at key transi- tion points (e.g., engagement) have also been devel- oped (Halford et al., 2008).
Research to date shows these skills-based education programs have modest but consistently positive effects
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RELATIONSHIPS 327
Effects of Divorce on the Couple. Divorce takes a high toll on the couple. Unlike the situation when one’s spouse dies, divorce often means the person’s ex-spouse is present to provide a reminder of the fail- ure. As a result, divorced people are typically unhappy in general, at least for a while. Especially because of the financial effects of divorce, the effects can even be traced to future generations due to long-term negative consequences on education (Amato & Cheadle, 2005). Divorced people suffer negative health consequences as well (Lamela, Figueiredo, & Bastos, in press).
Divorced people sometimes find the transition dif- ficult; researchers refer to these problems as “divorce hangover” (Walther, 1991). Divorce hangover reflects divorced partners’ inability to let go, develop new friendships, or reorient themselves as single parents. Forgiving the ex-spouse is also important for even- tual adjustment postdivorce (Rye et al., 2004). Both low preoccupation and forgiveness may be indicators ex-spouses are able to move on with their lives.
Divorce in middle age or late life has some spe- cial characteristics. If women initiate the divorce, they report self-focused growth and optimism; if they did not initiate the divorce, they tend to ruminate and feel vulnerable. Many middle-aged women who divorce also face significant financial challenges if their pri- mary source of income was the ex-husband’s earnings (Sakraida, 2005).
Remarriage The trauma of divorce does not deter people from begin- ning new relationships that often lead to another mar- riage. Typically, men and women both wait about 3.5 years before they remarry (National Center for Health Statistics, 2013a). However, remarriage rates vary some- what across ethnic groups. African Americans remarry a bit more slowly than other ethnic groups.
Although women are more likely to initiate a divorce, they are less likely to remarry unless they are
poor (National Center for, 2013a). However, women in general benefit more from remarriage than do men, particularly if they have children (Ozawa & Yoon, 2002). Although many people believe divorced indi- viduals should wait before remarrying to avoid the so- called “rebound effect,” there is no evidence those who remarry sooner have less success in remarriage than those who wait longer (Wolfinger, 2007).
Remarriage options for older adults after either divorce or the death of a spouse are often more con- strained. In some cases, widows may lose financial benefits from pensions or other retirement plans if they remarry. This problem exists for widows across cultures; in Namibia widows are constrained in their options and typically must depend on others (Thomas, 2008). Adult children may voice strong opposition to their parent remarrying that can put sufficient pres- sure on the parent that they remain single.
on marital quality and communication (Cowan, Cowan, & Knox, 2010; Fincham & Beach, 2010), and helps main- tain relationship satisfaction during marriage (Halford & Bodenmann, 2013).
These positive outcomes are resulting in a broad- ening of the approaches used by marriage educators
to topics beyond communication. How these programs develop, and whether more couples will participate, remains to be seen. What does appear to be the case is if couples agree to participate in a marriage education program, they may well lower their risk for problems later on.
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Adapting to new relationships in remarriage is stressful. Partners may have unresolved issues from the previous marriage that may interfere with satisfac- tion with the new marriage (Faber, 2004). The effects of remarriage on children is positive, at least for young adult children who report a positive effect on their own intimate relationships as an effect of their parent(s) remarrying happily (Yu & Adler-Baeder, 2007).
Widowhood Alma still feels the loss of her husband, Chuck. “There are lots of times when I feel him around. We were together for so long that you take it for granted that your husband is just there. And there are times when I just don’t want to go on without him. But I suppose I’ll get through it.”
Like Alma and Chuck, virtually all older married couples see their marriages end because one partner dies. For most people, the death of a partner is one of the most traumatic events they experience, causing an increased risk of death among older European Ameri- cans (but not African Americans), an effect that lasts several years (Moorman & Greenfield, 2010). An exten- sive study of widowed adults in Scotland showed the increased likelihood of dying lasted for at least 10 years (Boyle, Feng, & Raab, 2011). Despite the stress of los- ing one’s partner, most widowed older adults manage to cope reasonably well (Moorman & Greenfield, 2010).
Women are much more likely to be widowed than are men. More than half of all women over age 65 are widows, but only 15 % of men the same age are widow- ers. Women have longer life expectancies and typically marry men older than themselves. Consequently, the average married woman can expect to live at least 10 years as a widow.
The impact of widowhood goes well beyond the ending of a long-term partnership (Boyle et al., 2011; Guiaux, 2010). Loneliness is a major problem. Wid- owed people may be left alone by family and friends who do not know how to deal with a bereaved person. As a result, widows and widowers may lose not only a partner, but also those friends and family who feel uncomfortable with including a single person rather than a couple in social functions (Guiaux, 2010). Feel- ings of loss do not dissipate quickly, as the case of Alma shows clearly. Men and women react differently to wid- owhood. In general, those who were most dependent
on their partners during the marriage report the high- est increase in self-esteem in widowhood because they learned to do the tasks formerly done by their partners (Carr, 2004). Widowers may recover more slowly unless they have strong social support systems (Bennett, 2010). Widows often suffer more financially because survivor’s benefits are usually only half of their husband’s pensions (Weaver, 2010). For many women, widowhood results in difficult financial circumstances, particularly regard- ing medical expenses (McGarry & Schoeni, 2005).
For many reasons, including the need for compan- ionship and financial security, some widowed people cohabit or remarry. A newer variation on re-partnering is “living alone together,” an arrangement where two older adults form a romantic relationship but maintain separate living arrangements (Moorman & Greenfield, 2010). Re-partnering in widowhood can be difficult because of family objections (e.g., resistance from chil- dren), objective limitations (decreased mobility, poorer health, poorer finances), absence of incentives common to younger ages (desire for children), and social pressures to protect one’s estate (Moorman & Greenfield, 2010).
ADULT DEVELOPMENT IN ACTION As a marital therapist, how would you use data on factors that predict divorce?
11.3 Family Dynamics and the Life Course LEARNING OBJECTIVES
What is it like to be a parent? What are the key issues across ethnic groups? What forms of parenting are there? How does parenting develop across adulthood?
How do middle-aged adults interact with their children? How do they deal with the possibility of providing care to aging parents?
How do grandparents interact with their grandchildren? What key issues are involved?
S usan is a 42 -year-old married woman with two preadolescent children. She is an only child. Her mother, Esther, is a 67 -year-old widow and has been showing signs of dementia. Esther has little money and Susan’s family is
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RELATIONSHIPS 329
barely making ends meet. Susan knows her mother cannot live alone much longer, and she feels she should have her move in with their family. Susan feels she has an obliga- tion to provide care but also feels torn between her mother and her family and job. Susan wonders what to do.
Increasingly, families face the dilemma confront- ing Susan. As more people live long lives, the need for families to deal with health problems in their older members is on the rise.
In this section, we consider the dynamics of fami- lies, from deciding whether to have children through caring for aging parents and grandparenthood. As we do so, we must recognize the concept of “family” is undergoing change.
The Parental Role For one thing, the birth of a child transforms a couple (or a single parent) into a family. The most common form of family in Western societies is the nuclear family , consisting only of parent(s) and child(ren). The most common family form around the world is the extended family , in which grandparents and other relatives live with parents and children .
Deciding Whether to Have Children. One of the biggest decisions couples (and many singles) make is whether to have children. This decision appears complicated. You would think potential parents must weigh the many benefits of child rearing with the many
drawbacks. But apparently, this is not what most peo- ple actually do.
Rijken (2009) reports potential parents actually don’t think deliberately or deeply about when to have a child, and those who are career oriented or like their freedom do not often deliberately postpone parenthood because of those factors. Rather, thoughts about having children do not cross their minds until they are ready to begin thinking about having children. Whether the pregnancy is planned or not (and more than half of all U.S. pregnan- cies are unplanned), a couple’s first pregnancy is a mile- stone event in a relationship, with both benefits and costs (Greving, 2007; Meijer & van den Wittenboer, 2007). Parents largely agree children add affection, improve family ties, and give parents a feeling of immortality and sense of accomplishment. Most parents willingly sacri- fice a great deal for their children and hope they grow up to be happy and successful. In this way, children bring happiness to their parents (Angeles, 2010).
Nevertheless, finances are of great concern to most parents because children are expensive. How expensive? According to Lido (2012), a typical family who had a child in 2011 would spend about $ 206,000 for food, shelter, and other necessities by the time the child turns 17 . College expenses would be an additional expense. These costs do not differ significantly between two-parent and single-parent households but clearly are a bigger financial burden for single parents. Take a look at Figure 11.6 and see where the money goes.
0−2$0
Age of child 1U.S. average for the younger child in husband-wife families with two children.
Less than $59,410
$59, 410 to $102, 870
More than $102, 870
$5,000
$10,000
$15,000
$20,000
$25,000
3−5 6−8 9−11 12−14 15−17
Figure 11.6 Family expenditures on a child, by income level and age of child, 2011. USDA Expenditures on Children by Families, 2011, United States Department of Agriculture, Center for Nutrition Policy and Promotion, Miscellaneous Publication Number 1528–2011, p. 10, Figure 1
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330 CHAPTER 11
For many reasons that include personal choice, financial instability, and infertility, an increasing num- ber of couples are child-free. Social attitudes in many countries (Austria, Germany, Great Britain, Ireland, Netherlands, and United States) are improving toward child-free couples (Gubernskaya, 2010). Couples with- out children also have some advantages: higher marital satisfaction, more freedom, and higher standards of living.
Today, couples in the United States typically have fewer children and have their first child later than in the past. The average age at the time of the birth of a woman’s first child is nearly 25.5 (National Center for Health Statistics, 2013b). This average age has been increasing steadily since 1970 as a result of two major trends: Many women postpone children because they are marrying later, they want to establish careers, or they make a choice to delay childbearing. Nearly 41 % of mothers are unmarried.
Being older at the birth of one’s first child is advan- tageous. Older mothers are more at ease being par- ents, spend more time with their babies, and are more affectionate, sensitive, and supportive to them (Berlin, Brady-Smith, and Brooks-Gunn, 2002). The age of the father also makes a difference in how he interacts with children (Palkovitz & Palm, 2009). Compared to men who become fathers in their 20 s, men who become
fathers in their 30 s are generally more invested in their paternal role and spend up to 3 times as much time caring for their preschool children as younger fathers do. Father involvement has increased significantly, due in part to social attitudes that support it (Fogarty & Evans, 2010).
Ethnic Diversity and Parenting. Ethnic background matters a great deal in terms of family structure and the parent–child relationship. African American hus- bands are more likely than their European American counterparts to help with household chores, regard- less of their wives’ employment status (Dixon, 2009). Overall, most African American parents provide a cohesive, loving environment that often exists within a context of strong religious beliefs (Anderson, 2007; Dixon, 2009), pride in cultural heritage, self-respect, and cooperation with the family (Brissett-Chapman & Issacs-Shockley, 1997).
As a result of several generations of oppression, many Native American parents have lost traditional cultural parenting skills: Children were valued, women were considered sacred and honored, and men cared for and provided for their families (Witko, 2006).
Nearly 25 % of all children under 18 in the United States are Latino, and most are at least second gen- eration (National Center for Health Statistics, 2013b).
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RELATIONSHIPS 331
Among two-parent families, Mexican American moth- ers and fathers both tend to adopt similar authoritative behaviors toward their preschool children (Gamble, Ramakumar, & Diaz, 2007).
Latino families demonstrate two key values: familism and the extended family. Familism refers to the idea the well-being of the family takes precedence over the concerns of individual family members . This value is a defining characteristic of Latino families; Brazilian and Mexican families consider familism a cultural strength (Carlo et al., 2007; Lucero-Liu, 2007). Indeed, familism account for the significantly higher trend for Latino college students to live at home (Desmond & López Turley, 2009). The extended family is also strong among Latino families and serves as the venue for a wide range of exchanges of goods and services, such as child care and financial support (Almeida et al., 2009).
Asian Americans also value familism (Meyer, 2007) and place an even higher value on extended fam- ily. Other key values include obtaining good grades in school, maintaining discipline, being concerned about what others think, and conformity. Asian American adolescents report high feelings of obligation to their families compared with European American adoles- cents (Kiang & Fuligni, 2009). In general, males enjoy higher status in traditional Asian families (Tsuno & Homma, 2009).
Raising multi-ethnic children presents challenges not experienced by parents of same-race children. Par- ents of biracial children report feeling discrimination and they are targets of prejudicial behavior from others (Hubbard, 2010; Kilson & Ladd, 2009). These parents also worry their children may be rejected by members of both racial communities.
Single Parents. The proportion of births to unwed mothers in the United States is at an all-time high, now nearly 41 % (National Center for Health Statistics, 2013b). Rates vary by ethnic group. More than 70 % of births to African American mothers, more than 50 % of births to Latina mothers, and nearly 30 % of births to European American mothers are to unmar- ried women.
Many divorced single parents report complex feel- ings such as frustration, failure, guilt, and a need to be
overindulgent. Loneliness can be especially difficult to deal with (Anderson et al., 2004). Separation anxiety is a common and strong feeling among military parents who are about to be deployed (Roper, 2007).
Single parents, regardless of gender, face consider- able obstacles. Financially, they are usually much less well-off than their married counterparts. Integrating the roles of work and parenthood are more difficult. Single mothers are hardest hit, mainly because women typically are paid less than men.
One particular concern for many divorced single parents is dating. Single parents often feel insecure about sexuality and how they should behave around their children in terms of having partners stay over- night (Lampkin-Hunter, 2010).
Step-, Foster-, Adoptive, and Same-Sex Couple Parenting. Roughly one third of North American couples become stepparents or foster or adoptive par- ents some time during their lives. In general, there are few differences among parents who have their own bio- logical children or who become parents in some other way, but there are some unique challenges (McKay & Ross, 2010).
A big issue for foster parents, adoptive parents, and stepparents is how strongly the child will bond with them. Although infants less than 1 year old probably bond well, children who are old enough to have formed attachments with their biological par- ents may have competing loyalties. As a result, the dynamics in blended families can best be understood as a complex system (Dupuis, 2010). These prob- lems are a major reason second marriages are at high risk for dissolution, as discussed later in this chap- ter. They are also a major reason why behavioral and emotional problems are more common among step- children (Crohn, 2006).
Still, many stepparents and stepchildren ultimately develop good relationships with each other. Allowing stepchildren to develop a relationship with the step- parent at their own pace also helps. What style of stepparenting ultimately develops is influenced by the expectations of the stepparent, stepchild, spouse, and nonresidential parent (Crohn, 2006).
Adoptive parents also contend with attachment to birth parents, but in different ways. Adopted children
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332 CHAPTER 11
may wish to locate and meet their birth parents. Such searches can strain the relationships between these children and their adoptive parents who may inter- pret these actions as a form of rejection (Curtis & Pearson, 2010).
Families with children adopted from another cul- ture pose challenges of how to establish and maintain connection with the child’s culture of origin (Yngves- son, 2010). For mothers of transracially adopted Chi- nese and Korean children, becoming connected to the appropriate Asian American community is a way to accomplish this (Johnston et al., 2007). Research in the Netherlands found children adopted from Columbia, Sri Lanka, and Korea into Dutch homes struggled with looking different, and many expressed desires to be white (Juffer, 2006).
Foster parents have the most tenuous relationship with their children because the bond can be broken for any of a number of reasons having nothing to do with the quality of the care being provided. Deal- ing with attachment is difficult; foster parents want to provide secure homes, but they may not have the children long enough to establish continuity. Fur- thermore, because many children in foster care have been unable to form attachments at all, they are less likely to form ones will inevitably be broken. Despite the challenges, placement in good foster care results in the development of attachment between foster par- ents and children who were placed out of institutional settings (Smyke et al., 2010).
Finally, many gay men and lesbian women also want to be parents. Some have biological chil- dren themselves, whereas others choose adoption or foster parenting (Braun, 2007; Goldberg, 2009). Although gay men and lesbian women make good parents, they often experience resistance to their having children (Clifford, Hertz, & Doskow, 2010); Some states in the United States have laws prevent- ing gay and lesbian couples from adopting. Actually, research indicates children reared by gay or lesbian parents do not experience any more problems than children reared by heterosexual parents and are as psychologically healthy as children of heterosexual parents (Biblarz & Savci, 2010). Evidence shows gay parents have more egalitarian sharing of child rearing than do fathers in heterosexual households (Biblarz & Savci, 2010).
Midlife Issues: Adult Children and Caring for Aging Parents
Middle-aged family members, such as the current gen- eration of baby boomers, serve as the links between their aging parents and their own maturing children (Fingerman, Pillemer, Silverstein, & Suitor, 2012; Hareven, 2001). Middle-aged mothers (more than fathers) tend to take on this role of kinkeeper , the per- son who gathers family members together for celebra- tions and keeps them in touch with each other .
Think about the major issues confronting a typical middle-aged couple: maintaining a good marriage, par- enting responsibilities, dealing with children who are becoming adults themselves, handling job pressures, and worrying about aging parents, just to name a few. Middle-aged adults truly have a lot to deal with every day in balancing their responsibilities to their children and their aging parents (Riley & Bowen, 2005). Indeed, middle-aged adults are sometimes referred to as the sandwich generation because they are caught between the competing demands of two generations: their parents and their children .
Letting Go: Middle-Aged Adults and Their Children. Sometime during middle age, most parents experience two positive developments with regard to their chil- dren (Buhl, 2008). Suddenly their children see them in a new light, and the children leave home.
The extent parents foster and approve of their children’s attempts at being independent matters. Most parents manage the transition successfully (Owen, 2005). That’s not to say parents are heartless. As depicted in the cartoon, when children leave home, emotional bonds are disrupted. Mothers in all ethnic groups report feeling sad at the time children leave, but have more positive feelings about the potential for growth in their relationships with their children (Feld- man, 2010).
Still, parents provide considerable emotional sup- port (by staying in touch) and financial help (such as paying college tuition, providing a free place to live until the child finds employment) when possible (Mitchell, 2006; Warner, Henderson-Wilson, & Andrew, 2010).
A positive experience with launching children is strongly influenced by the extent the parents perceive a job well done and their children have turned out well
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RELATIONSHIPS 333
(Mitchell, 2010). Children are regarded as successes when they meet parents’ culturally based developmen- tal expectations, and they are seen as “good kids” when there is agreement between parents and children in basic values.
Parents’ satisfaction with the empty nest is some- times short-lived. Roughly half of young adults in the United States return to their parents’ home at least once after moving out (Osgood et al., 2005). There is evidence these young adults, called “boomerang kids” (Mitchell, 2006), reflect a less permanent, more mobile contemporary society.
Why do children move back? A major impetus is the increased costs of living on their own when sad- dled with college debt, especially if the societal eco- nomic situation is bad and jobs are not available. This was especially true during the Great Recession of the late 2000s and early 2010s.
Giving Back: Middle-Aged Adults and Their Aging Parents. Most middle-aged adults have parents who are in reasonably good health. But for nearly a quarter of adults, being a child of aging parents involves pro- viding some level of care (Feinberg, Reinhard, Houser, & Choula, 2011). How adult children become care providers varies a great deal from person to person,
but the job of caring for older parents usually falls to a daughter or a daughter-in-law (Barnett, 2013), and daughters also tend to coordinate care provided by multiple siblings (Friedman & Seltzer, 2010). In Japan, even though the oldest son is responsible for paren- tal care, it is his wife who actually does the day-to-day caregiving for her own parents and her in-laws (Lee, 2010).
Most adult children feel a sense of responsibil- ity, termed filial obligation , to care for their parents if necessary . Adult child care providers sometimes express the feeling they “owe it to Mom or Dad” to care for them; after all, their parents provided for them for many years, and now the shoe is on the other foot (Gans, 2007). Adult children often provide the majority of care when needed to their parents in all Western and non-Western cultures studied, but especially in Asian cultures (Barnett, 2013; Haley, 2013; Lai, 2010).
Roughly 50 million Americans provide unpaid care for older parents, in-laws, grandparents, and other older loved ones (National Alliance for Care- giving & AARP, 2010). The typical care provider is a 48 - year-old woman who is employed outside the home and provides more than 20 hours per week of unpaid care. These family care providers spend an average of
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334 CHAPTER 11
$ 7,000 per year in support of their loved one (National Endowment for Financial Education, 2010).
Stresses and Rewards of Providing Care. Providing care is a major source of both stress and reward. On the stress side, adult children and other family care- givers are especially vulnerable from two main sources (Pearlin et al., 1990):
Adult children may have trouble coping with declines in their parents’ functioning, especially those involving cognitive abilities and problematic behavior, and with work overload, burnout, and loss of the previous relationship with a parent.
If the care situation is perceived as confining or seriously infringes on the adult child’s other responsibilities (spouse, parent, employee, etc.), then the situation is likely to be perceived nega- tively, and that may lead to family or job conflicts, economic problems, loss of self-identity, and decreased competence.
When caring for an aging parent, even the most devoted adult child caregiver will at times feel depressed, resentful, angry, or guilty (Cavanaugh, 1999; Cohen, 2013; Haley, 2013). Many middle-aged care providers are hard pressed financially: They may still be paying child care or college tuition expenses, perhaps trying to save adequately for their own retire- ment, and having to work more than one job to do it. Financial pressures are especially serious for those caring for parents with chronic conditions, such as Alzheimer’s disease, that require services, such as adult day care, not adequately covered by medical insurance even if the older parent has supplemental coverage. In some cases, adult children may need to quit their jobs to provide care if adequate alternatives, such as adult day care, are unavailable or unaffordable, usually creat- ing even more financial stress.
The stresses of caring for a parent mean the care- giver needs to carefully monitor his or her own health. Indeed, many professionals point out caring for the care provider is an important consideration to avoid care provider burnout (Tamayo et al., 2010).
On the plus side, caring for an aging parent also has rewards. Caring for aging parents can bring parents and their adult children closer together and provide
a way for adult children to feel they are giving back to their parents (Miller et al., 2008). Cross-cultural research examining Taiwanese (Lee, 2007) and Chi- nese (Zhan, 2006) participants confirms adults caring for aging parents can find the experience rewarding.
Cultural values enter into the care providing rela- tionship in an indirect way (Knight & Sayegh, 2010). Care providers in all cultures studied to date show a common set of outcomes: Care providers’ stressors are appraised as burdensome, that creates negative health consequences for the care provider. However, cultural values influence the kinds of social support available to the care provider.
Things aren’t always rosy from the parents’ per- spective, either. Independence and autonomy are important traditional values in some ethnic groups, and their loss is not taken lightly. Older adults in these groups are more likely to express the desire to pay a professional for assistance rather than ask a family member for help; they may find it demeaning to live with their children and express strong feelings about “not wanting to burden them” (Cahill et al., 2009). Most move in only as a last resort. Many adults who receive help with daily activities feel negatively about the situation, although cultural norms supporting the acceptance of help, such as in Japanese culture, signifi- cantly lessen those feelings (Park, Kitayama, Karasawa, Curhan, Markus, Kawakami et al., 2013).
Determining whether older parents are satisfied with the help their children provide is a complex issue (Cahill et al., 2009; Park et al., 2013). Based on a criti- cal review of the research, Newsom (1999) proposes a model of how certain aspects of care can produce negative perceptions of care directly or by affecting the interactions between care provider and care recipi- ent (see Figure 11.7 ). The important thing to conclude from the model is even under the best circumstances, there is no guarantee the help adult children provide their parents will be well received. Misunderstandings can occur, and the frustration caregivers feel may be translated directly into negative interactions.
Understanding what resources are available to assist adult children who provide care for their parents is important. Take time and complete the Discovering Development feature to find out what is available in your local area.
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RELATIONSHIPS 335
Grandparenthood Becoming a grandparent takes some help. Being a par- ent yourself, of course, is a prerequisite. But it is your children’s decisions and actions that determine whether you experience the transition to grandparenthood, making this role different from most others we expe- rience throughout life. Most people become grand- parents in their 40 s and 50 s, though some are older, or perhaps as young as their late 20 s or early 30 s. For many middle-aged adults, becoming a grandparent is a peak experience (Gonyea, 2013; Hoffman, Kaneshiro, & Compton, 2012). Although most research on grand- parenting has been conducted with respect to het- erosexual grandparents, attention to lesbian, gay, and transsexual grandparents is increasing as these family forms increase in society (Orel & Fruhauf, 2013).
How Do Grandparents Interact with Grandchil- dren? Grandparents have many different ways of interacting with their grandchildren. Categorizing these styles has been attempted over many decades (e.g., Neugarten & Weinstein, 1964), but none of these
Figure 11.7 Whether a care recipient perceives care to be good depends on interactions with the care provider and whether those interactions are perceived negatively. Source: From Newsom, J. T. (1999). Another side to caregiv- ing: Negative reactions to being helped. Current Directions in Psychological Science, 8, 185. Reprinted by permission of Blackwell Publishing, Ltd.
Relationship variables (e.g., relationship conflict,
communication, reciprocity)
Caregiver variables (e.g., anger, depression,
burden, social skills)
Interactions with caregiver (e.g., help, support, conflict)
Negative reactions
Psychological well-being
Care recipient variables (e.g., self-esteem, control, need for independence, impairment, pessimism)
Situational variables (e.g., mood, pain,
life events, conflict)
Helping characteristics (e.g., inappropriate amount, quality of help, criticisms)
DISCOVERING DEVELOPMENT: CARING FOR AGING PARENTS As we have seen, caring for aging parents can be both stressful and uplifting. On the stress side, adult child care providers can experience significant health effects from long-term stress. Such stress is sometimes a factor in elder abuse, neglect, or exploitation. Thus, doing what is necessary to help deal with the stress- ful aspects of providing care is critical.
Communities typically have several sources of help for adult children who are caring for their aging parents. Find out what is available in your area. Check with local social service agencies, organizations dedi- cated to serving older adults, hospitals, colleges and universities, and churches and synagogues. You may be quite surprised to learn of the many options and opportunities there are for adults to get assistance. These may range from workshops and classes to sup- port groups to formal and informal outings.
Make a list of the programs you discover, and dis- cuss them in class. If possible, talk with individuals who run the programs and with people who take advan- tage of them to learn from all of their experiences.
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attempts has been particularly successful because grandparents use different styles with different grand- children and styles change as grandparents and grand- children age (Gonyea, 2013; Hoffman et al., 2012).
An alternative approach involves considering the many functions grandparents serve and the chang- ing nature of families (Hills, 2010). The social dimen- sion includes societal needs and expectations of what grandparents are to do, such as passing on family history to grandchildren. The personal dimension includes the personal satisfaction and individual needs fulfilled by being a grandparent. Many grandparents pass on skills—as well as religious, social, and voca- tional values (social dimension)—through storytelling and advice, and they may feel great pride and satisfac- tion (personal dimension) from working with grand- children on joint projects.
Grandchildren give grandparents a great deal in return. Grandchildren keep grandparents in touch with youth and the latest trends. Sharing the excite- ment of surfing the web in school may be one way grandchildren keep grandparents on the technological forefront.
Being a Grandparent Is Meaningful. Being a grandparent really matters. Most grandparents derive multiple meanings, and they are linked with generativ- ity (Gonyea, 2013; Thiele & Whelan, 2010). For some, grandparenting is the most important thing in their lives. For others, meaning comes from being seen as wise, from spoiling grandchildren, from recalling the relationship they had with their own grandparents, or from taking pride in the fact they will be followed by not one but two generations.
Grandchildren also highly value their relation- ships with grandparents, even when they are young adults (Alley, 2004). Grandparents are valued as role models as well as for their personalities, the activities they share, and the attention they show to grandchil- dren. Young adult grandchildren (ages 21 – 29 ) derive both stress and rewards from caring for grandparents, much the same way middle-aged adults do when they care for their aging parents (Fruhauf, 2007).
Ethnic Differences. How grandparents and grand- children interact varies in different ethnic groups. Intergenerational relationships are especially impor- tant and historically have been a source of strength in
African American families (Waites, 2009) and Latino families (Gladding, 2002). African American grand- parents play an important role in many aspects of their grandchildren’s lives, such as religious education (King et al., 2006). African American grandfathers, in partic- ular, tend to perceive grandparenthood as a central role to a greater degree than do European American grand- fathers (Kivett, 1991). Latino American grandparents are more likely to participate in child rearing owing to a cultural core value of family (Burnette, 1999).
Native American grandparents appear to have some interactive styles that differ from those of other groups (Weibel-Orlando, 1990). These grandparents provide grandchildren with a way to connect with their cultural heritage, and they are also likely to provide a great deal of care for their grandchildren (Mutchler, Baker, & Lee, 2007). Research also indicates Native American grandparents also use their own experiences of cultural disruption to reinvest in their
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RELATIONSHIPS 337
grandchildren to ensure the continuity of culture (Thompson, Cameron, & Fuller-Thompson, 2013). In general, Native American grandmothers take a more active role than do grandfathers, and are more likely to pass on traditional rituals (Woodbridge, 2008).
Asian American grandparents, particularly if they are immigrants, serve as a primary source of tradi- tional culture for their grandchildren (Yoon, 2005). When these grandparents become heavily involved in caring for their grandchildren, they especially want and need services that are culturally and linguistically appropriate.
When Grandparents Care for Grandchildren. Grandparenthood today is tougher than it used to be. Families are more mobile, and means grandparents are more often separated from their grandchildren by geographical distance. Grandparents are more likely to have independent lives apart from their children and grandchildren. What being a grandparent entails in the 21 st century is more ambiguous than it once was (Fuller-Thompson, Hayslip, & Patrick, 2005).
Perhaps the biggest change worldwide for grand- parents is the increasing number serving as custodial parents or primary caregivers for their grandchildren (Moorman & Greenfield, 2010). Estimates are about 7 million U.S. grandparents have grandchildren liv- ing with them, and 2.7 million of these grandparents provide basic needs (food, shelter, clothing) for one or more of their grandchildren (U.S. Census Bureau, 2012c). These situations result most often when both parents are employed outside the home (Uhlenberg & Cheuk, 2010); when the parents are deceased, addicted, incarcerated, or unable to raise their children for some other reason (Backhouse, 2006; Moorman & Green- field, 2010); or when discipline or behavior problems have been exhibited by the grandchild (Giarusso
et al., 2000). Lack of legal recognition stemming from the grandparents’ lack of legal guardianship also poses problems and challenges such as dealing with schools and obtaining records. Typically, social service work- ers must assist grandparents in navigating the many unresponsive policies and systems they encounter when trying to provide the best possible assistance to their grandchildren (Cox, 2007). Clearly, public policy changes are needed to address these issues, especially regarding grandparents’ rights regarding schools and health care for their grandchildren (Ellis, 2010).
Raising grandchildren is not easy. Financial stress, cramped living space, and social isolation are only some of the issues facing custodial grandmothers (Bullock, 2004). The grandchildren’s routines, activi- ties, and school-related issues also cause stress (Musil & Standing, 2005). All of these stresses are also reported cross-culturally; full-time custodial grandmothers in Kenya reported higher levels of stress than part-time caregivers (Oburu & Palmérus, 2005).
Even custodial grandparents raising grandchil- dren without these problems report more stress and role disruption than noncustodial grandparents, though most grandparents are resilient and manage to cope (Hayslip, Davis, Neumann, Goodman, Smith, Maiden et al., 2013). Most custodial grandparents con- sider their situation better for their grandchild than any other alternative and report surprisingly few nega- tive effects on their marriages.
ADULT DEVELOPMENT IN ACTION As a human resources director, what supports might you create to assist middle-aged adults handle family issues?
Social Policy Implications As we saw earlier in this chapter, elder abuse and neglect is a major, underreported global problem. To help protect vulnerable older adults, the U.S. Congress passed and President Obama signed into law the Elder Justice Act in 2010 as part of the Patient Protection and Affordable Care Act. It provides federal resources to
“prevent, protect, treat, understand, intervene in and, where appropriate, prosecute elder abuse, neglect and exploitation.”
In brief, the law requires the Department of Health and Human Services to oversee the management of fed- eral programs and resources for protecting older adults
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338 CHAPTER 11
Summary 11.1 Relationship Types and Issues
What role do friends play across adulthood? People tend to have more friendships during young
adulthood than during any other period. Friend- ships in old age are especially important for main- taining life satisfaction.
Men have fewer close friends and base them on shared activities. Women have more close friends and base them on emotional sharing. Cross-gender friendships are difficult.
What characterizes love relationships? How do they vary across culture?
Passion, intimacy, and commitment are the key components of love.
The theory that does the best job explaining the process of forming love relationships is the theory of assortative mating.
Selecting a mate works best when there are shared values, goals, and interests. There are cross-cultural differences in which specific aspects of these are most important.
What are abusive relationships? What characterizes elder abuse, neglect, or exploitation?
Levels of aggressive behavior range from verbal aggression to physical aggression to murdering
one’s partner. People remain in abusive relation- ships for many reasons, including low self-esteem and the belief they cannot leave.
Abuse, neglect, or exploitation of older adults is an increasing problem. Most perpetrators are spouses/partners or adult children. The causes are complex.
11.2 Lifestyles and Love Relationships
What are the challenges of being single? Most adults in their 20 s are single. People remain
single for many reasons; gender differences exist. Ethnic differences reflect differences in age at mar- riage and social factors.
Singles recognize the pluses and minuses in the lifestyle. There are health and longevity conse- quences from remaining single for men but not for women.
Why do people cohabit? Cohabitation is on the increase globally. Three primary reasons for cohabiting are conve-
nience (e.g., to share expenses), trial marriage, or substitute marriage.
What are gay and lesbian relationships like? Gay and lesbian couples are similar to married het-
erosexual couples in terms of relationship issues. Lesbian couples tend to be more egalitarian.
from abuse and neglect. Among the most important action steps in the law are:
• Establish the Elder Justice Coordinating Council • Establish an Advisory Board on Elder Abuse • Establish Elder Abuse, Neglect, and Exploitation
Forensic Centers • Enhance long-term care • Fund state and local adult protective service
offices • Provide grants for long-term care ombudsmen
programs and for evaluating programs • Provide training • Provide grants to state agencies to perform sur-
veys of care and nursing facilities • Require the U.S. Department of Justice to act to
prevent elder abuse by creating elder justice pro- grams, studying state laws and practices relat- ing to elder abuse, neglect, and exploitation,
train personnel, and ensure enough resources are available for investigation and prosecution of perpetrators.
Unfortunately, Congress has not appropriately funded this law as of 2013 (Blancato, 2013). Although the Violence Against Women Act that was reautho- rized in 2013 provides $ 9 million per year to assist older women, that is a far cry from the nearly $ 200 million per year authorized in the Elder Justice Act, and even more inadequate given that victims of financial exploi- tation alone lose roughly $ 3 billion per year.
Numerous national advocacy agencies, such as the Elder Justice Coalition, the National Adult Protec- tive Services Association, and others, are dedicated to ensuring the Elder Justice Act gets the funding it deserves. Child abuse prevention has been funded for years. It is time to help older adults be equally protected.
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RELATIONSHIPS 339
What is marriage like across adulthood? The most important factors in creating stable mar-
riages are maturity, similarity (called homogamy), and conflict resolution skills. Exchange theory is an important explanation of how people contribute to their relationships.
For couples with children, marital satisfaction tends to decline until the children leave home, although individual differences are apparent, especially in long-term marriages.
Most long-term marriages tend to be happy, and partners in them express fewer negative emotions.
Caring for a spouse presents challenges. How well it works depends on the quality of the marriage. Most caregiving spouses provide care based on love.
Why do couples divorce? Currently, half of all new marriages end in divorce.
Reasons for divorce include a lack of the qualities that make a strong marriage. Also, societal atti- tudes against divorce have eased and expectations about marriage have increased.
Recovery from divorce is different for men and women. Men tend to have a tougher time in the short run. Women clearly have a harder time in the long run, often for financial reasons. Difficulties between divorced partners usually involve visita- tion and child support.
Why do people remarry? Most divorced couples remarry. Second marriages
are especially vulnerable to stress if stepchildren are involved. Remarriage in later life tends to be happy, but may be resisted by adult children.
What are the experiences of widows and widowers? Widowhood is more common among women
because they tend to marry men older than they are. Widowed men typically are older.
Reactions to widowhood depend on the quality of the marriage. Men generally have problems in social relationships and in household tasks; women tend to have more financial problems.
11.3 Family Dynamics and the Life Course
What is it like to be a parent? What are the key issues across ethnic groups? What forms of parenting are there? How does parenting evolve across adulthood?
Most couples choose to have children, although for many different reasons. The timing of parenthood
determines in part how involved parents are in their families as opposed to their careers.
Instilling cultural values in children is important for parents. In some cultures, familism changes the unit of analysis from the individual to the family.
Single parents face many problems, especially if they are women and are divorced. The main prob- lem is reduced financial resources. A major issue for adoptive parents, foster parents, and stepparents is how strongly the child will bond with them. Each of these relationships has special characteristics. Gay and lesbian parents also face numerous obstacles, but they usually are good parents.
How do middle-aged adults get along with their children? How do they deal with the possibility of providing care to aging parents?
Most parents do not report severe negative emo- tions when their children leave. Difficulties emerge to the extent that children were a major source of a parent’s identity. However, parents typically report distress if adult children move back.
Middle-aged women often assume the role of kin- keeper to the family. Middle-aged parents may be squeezed by competing demands of their children, who want to gain independence, and their parents, who want to maintain independence; therefore, they are often called the sandwich generation.
Most caregiving by adult children is done by daughters and daughters-in-law. Filial obligation, the sense of responsibility to care for older parents, is a major factor.
Caring for aging parents can be highly stressful. Symptoms of depression, anxiety, and other prob- lems are widespread. Financial pressures also are felt by most. Parents often have a difficult time in accepting the care. However, many caregivers also report feeling rewarded or uplifted for their efforts.
How do grandparents interact with their grandchildren? What key issues are involved?
Being a grandparent is a meaningful role. Individ- ual differences in interactive style are large.
Ethnic differences in grandparenting are evident. Ethnic groups with strong family ties differ in style from groups who value individuality.
Grandparents are increasingly being put in the position of raising their grandchildren. Reasons include incarceration and substance abuse by the parents.
Great-grandparenthood is a role enjoyed by more people and reflects a sense of family renewal.
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340 CHAPTER 11
Review Questions 11.1 Relationship Types and Issues
How does the number and importance of friend- ships vary across adulthood?
What gender differences are there in the number and type of friends?
What are the components of love? What characteristics make the best matches
between adults? How do these characteristics dif- fer across cultures?
What is elder abuse, neglect, or exploitation? Why is it underreported?
11.2 Lifestyles and Love Relationships How do adults who never marry deal with the need
to have relationships? What are the relationship characteristics of gay and
lesbian couples? What are the most important factors in creating
stable marriages? What developmental trends are occurring in mari-
tal satisfaction? How do these trends relate to hav- ing children?
What factors are responsible for the success of long-term marriages?
What are the major reasons people get divorced? How are these reasons related to societal expecta- tions about marriage and attitudes about divorce?
What characteristics about remarriage make it simi- lar to and different from first marriage? How does satisfaction in remarriage vary as a function of age?
What are the characteristics of widowed people? How do men and women differ in their experience of widowhood?
11.3 Family Dynamics and the Life Course What ethnic differences are there in parent-
ing? What is familism and how does it relate to parenting?
What are the important issues in being an adoptive parent, foster parent, or stepparent? What special challenges are there for gay and lesbian parents?
What impact do children leaving home have on parents? Why do adult children return?
What are the important issues facing middle-aged adults who care for their parents?
How do grandparents and grandchildren relate? How do these relationships change with the age of the grandchild?
What ethnic differences have been noted in grand- parenting?
What are the important issues and meanings of being a great-grandparent?
INTEGRATING CONCEPTS IN DEVELOPMENT What components would a theory of adult rela-
tionships need to have? What are some examples of each of the four develop-
mental forces as they influence adult relationships? What role do the changes in sexual functioning dis-
cussed in Chapter 3 have on love relationships? What key public policy issues are involved in the
different types of adult relationships?
KEY TERMS abusive relationship A relationship that one partner displays aggressive behavior toward the other partner.
assortative mating A theory that people find partners based on their similarity to each other.
battered woman syndrome A situation where a woman believes she cannot leave an abusive relation- ship and that she may even go so far as to kill her abuser.
cohabitation Living with another person as part of a committed, intimate, sexual relationship.
exchange theory A theory of relationships based on the idea each partner contributes something to the relationship the other would be hard-pressed to provide.
familism Refers to the idea the well-being of the fam- ily takes precedence over the concerns of individual family members.
filial obligation The feeling that, as an adult child, one must care for one’s parents.
homogamy The notion similar interests and values are important in forming strong, lasting interpersonal relationships.
kinkeeper The person who gathers family members together for celebrations and keeps them in touch with each other.
marital adjustment The degree spouses accommodate each other over a certain period of time.
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RELATIONSHIPS 341
marital quality The subjective evaluation of the cou- ple’s relationship on a number of different dimensions.
marital satisfaction A global assessment of one’s marriage.
marital success An umbrella term referring to any marital outcome.
marriage education An approach based on the idea the more couples are prepared for marriage, the bet- ter the relationship will survive over the long run.
married singles Married couples who have grown apart but continue to live together.
sandwich generation Middle-aged adults caught between the competing demands of two generations: their parents and their children.
socioemotional selectivity A theory of relationships that argues social contact is motivated by a variety of goals, including information seeking, self-concept, and emotional regulation.
vulnerability-stress-adaptation model A model that sees marital quality as a dynamic process resulting from the couple’s ability to handle stressful events in the context of their particular vulnerabilities and resources.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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WORK, leisure, and retirement
12.1 OCCUPATIONAL SELECTION AND DEVELOPMENT The Meaning of Work • Occupational Choice Revisited • Occupational Development • Job Satisfaction • How Do We Know?: Cross-Cultural Aspects of Teachers’ Job Satisfaction
12.2 GENDER, ETHNICITY, AND DISCRIMINATION ISSUES Gender Differences in Occupational Selection • Women and Occupational Development • Ethnicity and Occupational Development • Bias and Discrimination • Current Controversies: Do Women Lean Out When They Should Lean In?
12.3 OCCUPATIONAL TRANSITIONS Retraining Workers • Occupational Insecurity • Coping with Unemployment • Discovering Development: What Unemployment Resources Are Available in Your Area?
12.4 WORK AND FAMILY The Dependent Care Dilemma • Juggling Multiple Roles
12.5 LEISURE ACTIVITIES Types of Leisure Activities • Developmental Changes in Leisure • Consequences of Leisure Activities
12.6 RETIREMENT AND WORK IN LATE LIFE What Does Being Retired Mean? • Why Do People Retire? • Adjustment to Retirement • Employment and Volunteering
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts In Development • Key Terms • Resources
Chapter 12
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WORK, LEISURE, AND RETIREMENT 343
For As Long As We Can Remember , people ask, “What do you want to be when you grow up?” When we are “grown up,” we simply change that question to “… and what do you do?” We are socialized throughout the life span that work is a central aspect of life and a defining characteristic of who we are. For some, work is life; for all, our jobs are at least a source of identity.
The world of work has changed dramatically over the past decade in large part to the experi- ences of the baby boomers who are redefining what it means to age, be engaged in meaningful activity, and ensure they have sufficient income to support the life style to which they have become accustomed. The Great Recession of the late 2000s and early 2010s also affected the workplace by forcing people who lost a significant part of their retirement savings to continue working, forcing middle-aged adults to find new employment fol- lowing loss of their job through layoff, and making it more difficult for younger adults to enter the workforce.
As a result, all issues regarding occupational preparation and selection now affect adults of all ages, from emerging adults to those in late life. We consider the complexities of the world of work throughout this chapter as we confront the reality of rapidly changing occupational conditions and
opportunities, and how those are shaping adult development and aging, and raising issues about basic assumptions people have about retirement.
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12.1 Occupational Selection and Development LEARNING OBJECTIVES
How do people view work? How do occupational priorities vary with age?
How do people choose their occupations? What factors influence occupational
development? What is the relationship between job satisfaction
and age?
Monique, a 28-year-old senior communications major, wonders about careers. Should she enter the broad- cast field as a behind-the-scenes producer, or would she be better suited as a public relations spokesperson? She thinks her outgoing personality is a factor she should con- sider in making this decision.
Choosing one’s work is serious business. Like Monique, we try to select a field in which we are trained and is also appealing. Work influences much of what we do in life. You may be taking this course as part of your preparation for a career in human development,
We We WW aarere sosociaciaalizlizlizededed frofroomm cm hilldhodhoodod to to thithihink nnk aboabobout u carreereers.s.
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344 CHAPTER 12
social services, psychology, nursing, allied, health, or other field. Work is a source for friends and often for spouses/partners. People arrange personal activities around work schedules. Parents often choose child- care centers on the basis of proximity to where they work. People often choose where they live in terms of where they work.
The Meaning of Work Studs Terkel, author of the fascinating classic book Working (1974), writes work is “a search for daily meaning as well as daily bread, for recognition as well as cash, for astonishment rather than torpor; in short, for a sort of life rather than a Monday through Friday sort of dying” (xiii). Kahlil Gibran (1923), in his mys- tical book The Prophet , put it this way: “Work is love made visible.”
The meaning most of us derive from work- ing includes both the money that can be exchanged for life’s necessities (and perhaps a few luxuries) and the possibility of personal growth (Rosso, Dekas, & Wrzesniewski, 2010).
What specific occupation a person holds appears to have no effect on his or her need to derive meaning from work. Finding meaning in one’s work can mean the difference between feeling work is the source of one’s life problems or a source of fulfillment and con- tentment (Grawitch, Barber, & Justice, 2010).
Researchers and career coaches write about four common meanings that describe work: developing self, union with others, expressing self, and serving oth- ers (Hyson, 2013; Lips-Wiersma, 2003). To the extent these meanings can all be achieved, people experience the workplace as an area of personal fulfillment, some- times describing it as a spiritual experience (Hyson, 2013). This provides a framework for understanding occupational selection and transition as a means to find better balance among the four.
Contemporary business theory supports the idea that meaning matters. The concept called meaning- mission fit explains how corporate executives with a better alignment between their personal intentions and their firm’s mission care more about their employees’ happiness, job satisfaction, and emotional well-being (Abbott, Gilbert, & Rosinski, 2013; French, 2007).
Because work plays such a key role in providing meaning for people, an important question is how
people select an occupation. Let’s turn our attention to two theories explaining how and why people choose the occupations they do.
Occupational Choice Revisited Decisions about what people want to do in the world of work do not initially happen in adulthood. Even by adolescence, there is evidence occupational prefer- ences are related to their personalities. But what are people preparing for? Certainly, much has been writ- ten about the rapidly changing nature of work and how people cannot prepare for a stable career where a per- son works for the same organization throughout his or her working life (Savickas, 2013).
Currently, it is more appropriate to consider careers as something people construct themselves rather than enter (Savickas, 2013). Career construction theory posits people build careers through their own actions that result from the interface of their own personal char- acteristics and the social context. What people “do” in the world of work, then, results from how they adapt to their environment, that in turn is a result of bio- psychosocial processes grounded in the collection of experiences they have during their life.
In this regard, two specific theories about how people adapt themselves to their environment have influenced research. First, Holland’s (1997) personal- ity-type theory proposes people choose occupations to optimize the fit between their individual traits (such as personality, intelligence, skills, and abilities) and their occupational interests. Second, social cognitive career theory (SCCT) proposes career choice is a result of the application of Bandura’s social cognitive theory, espe- cially the concept of self-efficacy.
Holland categorizes occupations by the interper- sonal settings that people must function and their associated lifestyles. He identifies six personality types that combine these factors: investigative, social, real- istic, artistic, conventional, and enterprising, that he believes are optimally related to occupations.
How does Holland’s theory help us understand the continued development of occupational interests in adulthood? Monique, the college senior in the vignette, found a good match between her outgoing nature and her major, communications. Indeed, college students of all ages prefer courses and majors that fit well with their own personalities. You are likely to be one of
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WORK, LEISURE, AND RETIREMENT 345
them. Later on, that translates into the tendency of people to choose occupations and careers they like.
Complementarily, social cognitive career theory proposes people’s career choices are heavily influenced by their interests (Lent, 2013; Sheu et al., 2010). As depicted in Figure 12.1 , SCCT has two versions. The simplest includes four main factors: Self-Efficacy (your belief in your ability), Outcome Expectations (what you think will happen in a specific situation), Interests (what you like), and Choice Goals (what you want to achieve). The more complex version also includes Sup- ports (environmental things that help you) and Barri- ers (environmental things that block or frustrate you). Several studies show support for the six-variable ver- sion of the model (Sheu et al., 2010).
How well do these theories work in actual practice, particularly in the rapidly changing world in which we live and where people’s careers are no longer stable? Certainly, the relations among occupation, personality, and demographic variables are complex (Clark, 2007). However, even given the lack of stable careers and the real need to change jobs frequently, there is still a strong tendency on people’s part to find occupations in which they feel comfortable and they like (Lent, 2013). As we will see later, loss of self-efficacy through job loss and long-term unemployment provides support for the role the self-statements underling self-efficacy and SCCT are key.
SCCT has also been used as a framework for career counselors and coaches to help people iden- tify and select both initial occupations and navigate
later occupational changes. The goal is to have people understand the work world changes rapidly and they need to develop coping and compensatory strategies to deal with that fact.
Although people may have underlying tendencies relating to certain types of occupations, unless they believe they could be successful in those occupations and careers they are unlikely to choose them. These beliefs can be influenced by external factors. Occu- pational prestige and gender-related factors need to be taken into account (Deng, Armstrong, & Rounds, 2007).
Occupational Development How a person advances in a career depends on the socialization that occurs when people learn the unwrit- ten rules of an organization.
Occupational Expectations. Especially in adoles- cence, people begin to form opinions about what work in a particular occupation will be like, based on what they learn in school and from their parents, peers, other adults, and the media. These expectations influ- ence what they want to become and when they hope to get there.
In adulthood, personal experiences affect peo- ple’s opinions of themselves as they continue to refine and update their occupational expectations and development (Fouad, 2007). This usually involves trying to achieve their occupational goal, monitoring progress toward it, and changing or even abandoning
Figure 12.1 The four-variable (paths 1–6) and six-variable (paths 1–13) versions of the SCCT interest and choice models. © 2015 Cengage Learning
Self-Efficacy
Supports
12 11
13
10
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Barriers
Interests Choice Goals
Outcome Expectations
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it as necessary. Modifying the goal happens for many reasons, such as realizing interests have changed, the occupation was not a good fit for them, they never got the chance to pursue the level of education neces- sary to achieve the goal, or because they lack certain essential skills and cannot acquire them. Still other people modify their goals because of age, race, or sex discrimination, a point we consider later in this chapter.
Research shows most people who know they have both the talent and the opportunity to achieve their occupational and career goals often attain them. When high school students identified as academically tal- ented were asked about their career expectations and outcomes, it turned out that 10 and even 20 years later they had been surprisingly accurate (Perrone et al., 2010). What is also clear from research is the biggest change has been in women’s occupational and career expectations (Jacob & Wilder, 2010).
In general, research shows young adults modify their expectations at least once, usually on the basis of new information, especially about their academic abil- ity. The connection between adolescent expectations and adult reality reinforces the developmental aspects of occupations and careers.
Many writers believe occupational expectations also vary by generation. Nowhere has this belief been stronger than in the supposed differences between the baby boom generation (born between 1946 and 1964) and the current millennial generation (born since 1983). What people in these generations, on average, expect in occupations appears to be different (Her- shatter & Epstein, 2010). Millennials are more likely to change jobs more often than the older generations did, and are likely to view traditional organizations with more distrust and cynicism.
Contrary to most stereotypes, millennials are no more egotistical, and are just as happy and satisfied as young adults in every generation since the 1970s (Trz- esniewski & Donnellan, 2010). However, millennials tend to have an inherent mistrust in organizations, prefer a culture focused on employee development, create information through interactive social media, are more globally aware and comfortable working with people from diverse socio-ethnic backgrounds, and do best in situations that value innovation through team- work (Dannar, 2013).
The importance of occupational expectations can be seen clearly in the transition from school to the workplace (Moen & Roehling, 2005). The 21 st-century workplace is not one where hard work and long hours necessarily lead to a stable career. It can also be a place where you experience reality shock , a situation that what you learn in the classroom does not always transfer directly into the “real world” and does not represent all you need to know. When reality shock sets in, things never seem to happen the way we expect. Reality shock befalls every- one. You can imagine how a new teacher feels when her long hours preparing a lesson result in students who act bored and unappreciative of her efforts.
Many professions, such as nursing and teaching, have gone to great lengths to alleviate reality shock (Alhija & Fresko, 2010; Hinton & Chirgwin, 2010). This problem is one best addressed through intern- ship and practicum experiences for students under the careful guidance of experienced people in the field.
The Role of Mentors and Coaches. Entering an occupation involves more than the relatively short for- mal training a person receives. Instead, most people are oriented by a more experienced person who makes a specific effort to do this, taking on the role of a men- tor or coach .
A mentor or developmental coach is part teacher, sponsor, model, and counselor who facilitates on-the- job learning to help the new hire do the work required in his or her present role and to prepare for future roles (Hunt & Weintraub, 2006). Mentoring and coaching are viewed as primary ways that organizations invest in developing their talent and future leadership (Smits & Bowden, 2013).
The mentor helps a young worker avoid trouble and also provides invaluable information about the unwritten rules governing day-to-day activities in the workplace, and being sensitive to the employment situ- ation (Smith, Howard, & Harrington, 2005). As part of the relationship, a mentor makes sure the protégé is noticed and receives credit from supervisors for good work. Thus, occupational success often depends on the quality of the mentor–protégé relationship and the protégé’s perceptions of its importance (Eddleston, Baldridge, & Veiga, 2004). In times of economic down- turns, mentors can provide invaluable advice on find- ing another job (Froman, 2010).
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WORK, LEISURE, AND RETIREMENT 347
What do mentors get from the relationship? Helping a younger employee learn the job is one way to fulfill aspects of Erikson’s phase of generativity. As we saw in Chapter 9 , generativity reflects middle- aged adults’ need to ensure the continuity of society through activities such as socialization or having chil- dren. Mentoring is an important way generativity can be achieved (Marcia & Josselson, in press). Addition- ally, leaders may need to serve as mentors to activate transformational leadership (leadership that changes the direction of an organization) and promote positive work attitudes and career expectations of followers, enabling the mentor to rise to a higher level in his or her own career (Scandura & Williams, 2004).
Women and minorities have an especially impor- tant need for mentors (Ortiz-Walters & Gilson, 2013; Pratt, 2010). When paired with mentors, women ben- efit by having higher expectations; mentored women also have better perceived career development (Enslin,
2007). Latina nurses in the U.S. Army benefitted from mentors in terms of staying in the military and getting better assignments (Aponte, 2007). It is also critical to adopt a culturally conscious model of mentoring in order to enhance the advantages of developing minor- ity mentees (Campinha-Bacote, 2010). Culturally conscious mentoring involves understanding how an organization’s culture affects employees and building those assumptions and behaviors into the mentoring sit- uation. Culturally conscious mentoring can also involve addressing the cultural background of an employee and incorporating that into the mentoring relationship.
Despite the evidence that having a mentor has many positive effects on one’s occupational development, there is an important caveat; the quality of the men- tor really matters (Tong & Kram, 2013). Having a poor mentor is worse than having no mentor at all. Conse- quently, prospective protégés must be carefully matched with a mentor and mentorship programs need to select motivated and skilled individuals who are provided with extensive training. It is in the best interest of the organi- zation to get the mentor-protégé match correct.
How can prospective mentors and protégés meet more effectively? Some organizations have taken a page from dating and created speed mentoring as a way to create better matches (Berk, 2010; Cook, Bahn, & Menaker, 2010).
Job Satisfaction What does it mean to be satisfied with one’s job or occupation? Job satisfaction is the positive feeling that results from an appraisal of one’s work . Research indi- cates job satisfaction is a multifaceted concept but certain characteristics—including hope, resilience, optimism, and self-efficacy—predict both job perfor- mance and job satisfaction (Luthans et al., 2007).
Satisfaction with some aspects of one’s job increases gradually with age, and successful aging includes a workplace component (Robson et al., 2006). Why is this? Is it because people sort themselves out and end up in occupations they like? Is it they simply learn to like the occupation they are in? What other factors matter?
For starters, the factors that predict job satisfac- tion differ somewhat across cultures (Klassen, Usher, & Bong, 2010). This is explored in more detail in the Spotlight on Research feature.
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348 CHAPTER 12
So how does job satisfaction evolve over young and middle adulthood? You may be pleased to learn research shows, given sufficient time, most people eventually find a job where they are reasonably happy (Hom & Kinicki, 2001). Optimistically, this indicates there is a job out there, somewhere, where you will be happy. That’s good, because research grounded in
positive psychology theory indicates happiness fuels success (Achor, 2010).
It’s also true job satisfaction does not increase in all areas and job types with age. White-collar pro- fessionals show an increase in job satisfaction with age, whereas those in blue-collar positions generally do not, and these findings hold with both men and
HOW DO WE KNOW?: CROSS-CULTURAL ASPECTS OF TEACHERS’ JOB SATISFACTION Who were the investigators and what was the aim of the study? Robert Klassen, Ellen Usher, and Mimi Bong wondered about the similarities and differences in teachers’ job satisfaction, self-efficacy, and job stress. To find out, they studied teachers in the United States, Korea, and Canada. Their main question was whether teachers’ cultural values, self-efficacy, and job stress would predict job satisfaction across the three countries.
How did the investigators measure the topic of interest? The researchers measured self-efficacy by assessing teachers’ individual perceptions about their school’s collective capabilities to influence student achievement. Job satisfaction was measured through four rating scales: (1) “I am satisfied with my job,” (2) “I am happy with the way my colleagues and superi- ors treat me,” (3) “I am satisfied with what I achieve at work,” and (4) “I feel good at work.” Job stress was measured using a single item (“I find teaching to be very stressful”). Collectivism, a cultural value, was measured with a 6 -item scale where the first part of the question was, “In your opinion, how important is it that you and your family … ,” with the conclusion of the items includ- ing the following: (1) “take responsibility for caring for older family members?” (2) “turn to each other in times of trouble?” (3) “raise each other’s children whenever there is a need?” (4) “do everything you can to help each other move ahead in life?” (5) “take responsibil- ity for caring for older family members?” and (6) “call, write, or see each other often?”. The Korean version of the scales was created using a translation–back-trans- lation process to ensure the meaning of the items was preserved.
Who were the participants in the study? A total of 500 elementary and middle school teachers from the United States ( n = 137 ) , Canada ( n = 210 ) , and Korea ( n = 153 ) participated. The sample from the United States was included to connect this study to other research on teachers’ job satisfaction. Canadian
teachers were included to determine the degree find- ings from the United States could be generalized to a country holding similar (but not identical) cultural val- ues. The Korean teachers represented a group with a different geographic and demographic profile (East Asian, Confucian, Collectivist). Careful analyses showed no significant differences in age, teaching experience, job satisfaction, collective efficacy, job stress, or cultural values across the three countries.
What was the design of the study? The study used a cross-sectional design.
Were there ethical concerns with the study? Because the study involved voluntary completion of a survey, there were no ethical concerns.
What were the results? The analyses revealed North American teachers scored higher on all the vari- ables than the Korean teachers. However, there were no differences across countries regarding the efficacy of the teachers and either the strength or direction of its relation to job satisfaction. In contrast, analyses also revealed job stress had a bigger impact for North Amer- ican teachers whereas the cultural value of collectivism was more important for Korean teachers.
What did the investigators conclude? The most important finding from the study is the similar- ity across countries in the connection between the efficacy teachers believe they have and their job satisfaction—the less efficacy, the lower a teacher’s satisfaction is likely to be. Second, the higher impor- tance of the cultural value of collectivism for Korean teachers probably reflects a cultural norm of avoiding conflict and working for the betterment of the group. Finally, the finding that job stress was a negative pre- dictor of job satisfaction for North American teach- ers (the higher the stress, the lower the satisfaction) but a positive predictor for Korean teachers (higher job stress predicted higher satisfaction) indicates job stress may have different components as a function of culture. For Korean teachers, feeling stressed by the presence of more competent teachers may create an urge to improve, rather than a feeling of defeat. In summary, some predictors of job satisfaction tran- scend countries; others do not.
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WORK, LEISURE, AND RETIREMENT 349
women (Aasland, Rosta, & Nylenna, 2010). This is also true across cultures. A study of Filipino and Taiwanese workers in the long-term health care industry in Tai- wan showed workers with 4 or 5 years’ experience had lower job satisfaction than workers with less experi- ence, but job satisfaction among older physicians in Norway increases over time (Aasland et al., 2010; Tu, 2007).
However, the changes in the labor market in terms of lower prospects of having a long career with one organization have begun to change the notion of job satisfaction (Bidwell, 2012; Böckerman, Ilmakunnas, Jokisaari, & Yuori, 2013). Specifically, the fact that companies may eliminate jobs and workers not based on performance, making it more difficult for employ- ees to develop a sense of organizational commitment, has made the relationship between worker age and job satisfaction more complicated.
Also complicating traditional relations between job satisfaction and age is the fact that the type of job one has and the kinds of family responsibilities one has at different career stages—as well as the flexibility of work options such as telecommuting and family leave benefits to accommodate those responsibilities— influence the relationship between age and job satis- faction (Marsh & Musson, 2008). This suggests the accumulation of experience, changing context, and the stage of one’s career development may contribute to the increase in job satisfaction over time, as does the availability of options such as telecommuting.
Alienation and Burnout. All jobs create a certain level of stress. For most workers, such negatives are merely annoyances. But for others, extremely stress- ful situations on the job may result in alienation and burnout.
When workers feel what they are doing is meaning- less and their efforts are devalued, or when they do not see the connection between what they do and the final product, a sense of alienation is likely to result . Terkel (1974) reported employees are most likely to feel alien- ated when they perform routine, repetitive actions. Other workers can become alienated, too. The Great Recession that began in 2008 and resulted in record levels of job loss is only the most recent example of even high-level managerial employees feeling aban- doned by their employers.
It is essential for companies to provide positive work environments to ensure the workforce remains stable and committed (Griffin et al., 2010). How can employers avoid alienating workers and improve orga- nizational commitment? Research indicates trust is key (Chen, Aryee, & Lee, 2005; Sousa-Lima, Michel, & Caetano, 2013), as is a perception among employ- ees the employer deals with people fairly and impar- tially (Howard & Cordes, 2010). It is also helpful to involve employees in the decision-making process, create flexible work schedules, and institute employee development and enhancement programs. Employees in organizations that foster trust are also more likely to want to stay (Sousa-Lima et al., 2013).
Sometimes the pace and pressure of the occupa- tion becomes more than a person can bear, resulting in burnout , a depletion of a person’s energy and motiva- tion, the loss of occupational idealism, and the feeling that one is being exploited. Burnout is a state of physi- cal, emotional, and mental exhaustion as a result of job stress (Malach-Pines, 2005). Burnout is most com- mon among people in the helping professions—such as police (McCarty & Skogan, 2013), teaching, social work, health care (Bozikas et al., 2000), and occu- pational therapy (Bird, 2001)—and for those in the military (Harrington et al., 2001). The tendency of companies to keep employee numbers smaller during times of economic uncertainty adds to the workload for people on the job, increasing the risk of burnout (Bosco, di Masi, & Manuti, 2013).
People in these professions and situations must constantly deal with other people’s complex problems, usually under difficult time constraints. Dealing with these pressures every day, along with bureaucratic paperwork, may become too much for the worker to bear. Frustration builds, and disillusionment and exhaustion set in—burnout. Burnout negatively affects the people who are supposed to receive services from the burned-out employee (Rowe & Sherlock, 2005).
We know burnout does not affect everyone in a par- ticular profession. Why? Vallerand (2008; Carbonneau & Vallerand, 2012) proposes the difference relates to people feeling different types of passion (obsessive and harmonious) toward their jobs. A passion is a strong inclination toward an activity individuals like (or even love), they value (and thus find important), and where they invest time and energy (Vallerand et al., 2010).
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350 CHAPTER 12
Vallerand’s (2008) Passion Model proposes people develop a passion toward enjoyable activities that are incorporated into identity.
Vallerand’s model differentiates between two kinds of passion: obsessive and harmonious. A criti- cal aspect of obsessive passion is the internal urge to engage in the passionate activity makes it difficult for the person to fully disengage from thoughts about the activity, leading to conflict with other activities in the person’s life (Vallerand et al., 2010).
In contrast, harmonious passion results when individuals do not feel compelled to engage in the enjoyable activity; rather, they freely choose to do so and it is in harmony with other aspects of the person’s life (Vallerand et al., 2010).
Research in France and Canada indicate the Pas- sion Model accurately predicts employees’ feelings of burnout (Vallerand, 2008; Vallerand et al., 2010). As shown in Figure 12.2 , obsessive passion predicts higher levels of conflict that in turn predicts higher levels of burnout. In contrast, harmonious passion predicts higher levels of satisfaction at work, and predicts lower levels of burnout.
The best ways to lower burnout are intervention programs that focus on both the organization and the employee (Awa, Plaumann, & Walter, 2010) and foster passion (Vallerand, 2012). At the organizational level, job restructuring and employee-provided programs are important. For employees, stress-reduction techniques, lowering other people’s expectations, cognitive restruc- turing of the work situation, and finding alternative ways to enhance personal growth and identity are most effective (van Dierendonck, Garssen, & Visser, 2005).
Figure 12.2 Model of the relations among passion, satisfaction at work, conflict, and burnout. Harmonious passion predicts higher levels of satisfaction at work that predict lower levels of burnout. In contrast, obsessive passion predicts higher levels of conflict, predicting higher levels of burnout. ***p < .001. Source: From “On the role of passion for work in burnout: A process model,” by R. J. Vallerand, Y. Paquet, F. L. Philippe, and J. Charest, in Journal of Personality, Vol. 78.
.78
.33***
–.33***
.49***
.51***
–.12 .35***
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Obsessive PASSION
Harmonious PASSION
Conflict
Satisfaction at WORK
Burnout
Adult Development In Action What would be the key aspects of creating an orga- nization that fosters employee commitment and low levels of burnout?
12.2 Gender, Ethnicity, and Discrimination Issues LEARNING OBJECTIVES
How do women’s and men’s occupational expectations differ? How are people viewed when they enter occupations not traditional for their gender?
What factors are related to women’s occupational development?
What factors affect ethnic minority workers’ occupational experiences and occupational development?
What types of bias and discrimination hinder the occupational development of women and ethnic minority workers?
Janice, a 35-year-old African American manager at a business consulting firm, is concerned because her career is not progressing as rapidly as she hoped. Janice works hard and received excellent performance ratings every year. She noticed there are few women in upper management positions in her company. Janice wonders whether she will ever be promoted.
Occupational choice and development are not equally available to all, as Janice is experiencing.
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WORK, LEISURE, AND RETIREMENT 351
Gender, ethnicity, and age may create barriers to achieving one’s occupational goals. Men and women in similar occupations may nonetheless have different life experiences and probably received different socializa- tion as children and adolescents that made it easier or difficult for them to set their sights on a career. Bias and discrimination also create barriers to occupational success.
Gender Differences in Occupational Selection
About 58 % of all women over age 16 in the United States participate in the labor force (down from its peak of 60 % in 1999), and they represent roughly 47 % of the total workforce (Bureau of Labor Statistics, 2013a).
Across ethnic groups, African American women participate the most (about 59 % ) and Latina women the least (about 56 % ). Compared to other countries, women in the United States tend to be employed at a higher rate (see Figure 12.3 ). Still, structural barri- ers remain for women in the United States. Let’s take a look at both traditional and nontraditional occupa- tions for women.
In the past, women employed outside the home entered traditional, female-dominated occupations such as secretarial, teaching, and social work jobs. This was mainly because of their socialization into these occupational tracks. However, as more women enter the workforce and new opportunities are opened, a growing number of women work in occupations that have been traditionally male-dominated, such
Figure 12.3 Women’s labor force participation rates in selected countries, 1970–2010. Source: From “Women at work,” by U.S. Bureau of Labor Statistics, p. 13, 2011.
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352 CHAPTER 12
as construction and engineering. The U.S. Department of Labor (2013a) categorizes women’s nontraditional occupations as those where women constitute 25 % or less of the total number of people employed; the skilled trades (electricians, plumbers, carpenters) still have among the lowest participation rates of women. Trends can be seen in Figure 12.4 .
Despite the efforts to counteract gender stereotyp- ing of occupations, women who choose nontraditional occupations and are successful in them are viewed negatively as compared with similarly successful men.
In patriarchal societies, both women and men gave higher “respectability” ratings to males than females in the same occupation (Sharma & Sharma, 2012). In the United States, research shows men still prefer to date
women who are in traditional careers (Kapoor et al., 2010). Additionally, compared to women who work in traditional occupations, women who work in non- traditional occupations are less likely to believe they are being sexually harassed when confronted with the same behavior (Bouldin & Grayson, 2010; Maeder, Wiener, & Winter, 2007).
Women and Occupational Development The characteristics and aspirations of women who entered the workforce in the 1950s and those from the Baby Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1982), and the Millennials (born since 1983) are significantly differ- ent (Dannar, 2013; Strauss & Howe, 2007). Women
Figure 12.4 Employment of women by industry, 1964–2010. Source: From “Women at work,” by U.S. Bureau of Labor Statistics, p. 11, 2011.
19 64
0
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30
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Education & health services
Trade, transportation, &
utilities
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Professional & business services
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Financial activities
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State government
Federal government
Information Construction
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M ill
io ns
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WORK, LEISURE, AND RETIREMENT 353
in previous generations had fewer opportunities for employment choice and had to overcome more barriers.
In the 21 st century, women entrepreneurs are starting small businesses at a faster rate than men and are finding a home-based business can solve many of the challenges they face in balancing employment and a home life. As the millennial generation heads into the workforce, it will be interesting to see whether their high degree of technological sophistication will pro- vide more occupational and career options. Techno- logically mediated workplaces may provide solutions to many traditional issues, such as work–family con- flict. When millennial generation women choose non- traditional occupations, their attitudes toward them are more similar to previous generations’ attitudes (Real, Mitnick, & Maloney, 2010).
In the corporate world, unsupportive or insensi- tive work environments, organizational politics, and the lack of occupational development opportunities are most important for women working full-time (Yamini- Benjamin, 2007). Female professionals leave their jobs for two main reasons. First, the organizations where women work are felt to idealize and reward masculine values of working—individuality, self-sufficiency, and individual contributions—while emphasizing tangible outputs, competitiveness, and rationality. Most women prefer organizations that highly value relationships, interdependence, and collaboration.
Second, women may feel disconnected from the workplace. By midcareer, women may conclude they must leave these unsupportive organizations in order to achieve satisfaction, growth, and development at work and rewarded for the relational skills they con- sider essential for success. As we see a bit later, whether women leave their careers or plateau before reaching their maximum potential level in the organization because of lack of support, discrimination, or personal choice is controversial.
Ethnicity and Occupational Development Unfortunately, little research has been conducted from a developmental perspective related to occu- pational selection and development for people from ethnic minorities. Rather, most researchers focused on the limited opportunities ethnic minorities have
and on the structural barriers, such as discrimination, they face.
Women do not differ significantly in terms of par- ticipation in nontraditional occupations across ethnic groups (Bureau of Labor Statistics, 2013a). However, African American women who choose nontraditional occupations tend to plan for more formal education than necessary to achieve their goal. This may actu- ally make them overqualified for the jobs they get; a woman with a college degree may be working in a job that does not require that level of education.
Latino Americans are similar to European Americans in occupational development and work values.
Whether an organization is responsive to the needs of ethnic minorities makes a big difference for employ- ees. Ethnic minority employees of a diverse organiza- tion in the Netherlands reported more positive feelings about their workplace when they perceived their orga- nizations as responsive and communicative in sup- portive ways (Dinsbach, Fiej, & de Vries, 2007).
Bias and Discrimination Since the 1960s, organizations in the United States have been sensitized to the issues of bias and discrimi- nation in the workplace.
Gender Bias and the Glass Ceiling. By the end of the first decade of the 21 st century, women accounted for more than half of all people employed in manage- ment, professional, and related occupations (Bureau of Labor Statistics, 2013b). However, women are still underrepresented at the top. Janice’s observation in the vignette that few women serve in the highest ranks of major corporations is accurate.
Why are there so few women in such positions? The most important reason is gender discrimination : denying a job to someone solely on the basis of whether the person is a man or a woman . Gender discrimina- tion is still pervasive in too many aspects of the work- place (Purcell, MacArthur, & Samblanet, 2010).
Research in the United States and Britain also confirms women are forced to work harder than men (Gorman & Kmec, 2007). Neither differences in job characteristics nor family obligations account for this difference; the results clearly point to stricter job per- formance standards being applied to women.
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Women themselves refer to a glass ceiling , the level they may rise within an organization but beyond which they may not go . The glass ceiling is a major barrier for women (Johns, 2013; Purcell et al., 2010), and the greatest barrier facing them is at the bound- ary between lower-tier and upper-tier grades. Men are largely blind to the existence of the glass ceiling ( Heppner, 2007).
The glass ceiling is pervasive across higher man- agement and professional workplace settings (Heppner, 2007; Johns, 2013). Despite decades of attention to the issue, little overall progress is being made in the num- ber of women who lead major corporations or serve on their boards of directors (Cundiff & Stockdale, 2013). The glass ceiling has also been used to account for African Americans’ and Asian Americans’ lack of advancement in their careers as opposed to European
American men (Cundiff & Stockdale, 2013; Hwang, 2007). It also provides a framework for understand- ing limitations to women’s careers in many countries around the world such as South Africa (Kiaye & Singh, 2013).
Interestingly, a different trend emerges if one examines who is appointed to critical positions in organizations in times of crisis. Research shows at such times, women are more likely put in leadership positions. Consequently, women often confront a glass cliff where their leadership position is precarious. Evi- dence shows companies are more likely to appoint a woman to their board of directors if their financial performance had been poor in the recent past, and women are more likely to be political candidates if the seat is a highly contested one (Ryan, Haslam, & Kulich, 2010).
What can be done to eliminate the glass ceiling and the glass cliff ? Kolb, Williams, and Frohlinger (2010) argue women can and must be assertive in get- ting their rightful place at the table by focusing on five key things: drilling deep into the organization so you can make informed decisions, getting critical support, getting the necessary resources, getting buy-in, and making a difference.
Much debate has erupted over the issue of women rising to the top. There is no doubt the glass ceiling and glass cliff exist. The controversy surrounds the extent women decide not to pursue or reluctance to pursue the top positions. As discussed in the Current Contro- versies feature, this debate is likely to rage for years.
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CURRENT CONTROVERSIES: DO WOMEN LEAN OUT WHEN THEY SHOULD LEAN IN? Sheryl Sandberg is unquestionably successful. She has held the most important, powerful positions in the most recognizable technology companies in the world. When she published her book Lean In: Women, Work, and the Will to Lead in 2013, she set off a fierce debate. Sandberg claimed there is discrimination against women in the corporate word. She also argued an important reason women do not rise to the top more often is because of their own unintentional behavior that holds them back. She claimed women do not speak up enough, need to abandon the myth of “having it
all,” set boundaries, get a mentor, and not to “check out of work” when thinking about starting a family.
The national debate around these issues raised many issues: Sandberg’s ability to afford to pay for sup- port may make her points irrelevant for women who do not have those resources; her husband’s ability and will- ingness to share in child rearing and household chores may make her arguments irrelevant for single parents; she was “blaming the victim”; no one ever puts men in these situations of having to choose; and so on.
Does Sheryl Sandberg have a valid point to make? Do men and women differ in how they approach careers? Are the differences she notes inherent in men and women or are they more learned? What support systems that need to be in place are currently missing? What do you think?
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WORK, LEISURE, AND RETIREMENT 355
Equal Pay for Equal Work. In addition to discrimi- nation in hiring and promotion, women are also subject to salary discrimination. According to the Bureau of Labor Statistics (2013a), women’s median income overall is about 81 % of men’s. As you can see in Figure 12.5 , the wage gap depends on ethnicity and has been narrowing since the 1980s.
The Social Policy Implications feature at the end of the chapter discusses equal pay for equal work in more detail. In general, although few people disagree with the principle, eliminating the salary disparity between men and women has proven more difficult than many originally believed.
Sexual Harassment. Suppose you have been working hard on a paper for a course and think you’ve done a good job. When you receive an “A” for the paper, you are elated. When you discuss your paper (and your
excitement) with your instructor, you receive a big hug. How do you feel? What if this situation involved a major project at work and the hug came from your boss? Your co-worker? What if it were a kiss on your lips instead of a hug?
Whether such behavior is acceptable, or whether it constitutes sexual harassment, depends on many situ- ational factors, including the setting, people involved, and the relationship between them.
How many people have been sexually harassed? That’s a hard question to answer for several reasons: there is no universal definition of harassment, men and women have different perceptions, and many victims do not report it (The Advocates for Human Rights, 2010). Even given these difficulties, global research indicates between 40 % and 50 % of women in the European Union, and 30 – 40 % of women in Asia-Pacific countries experience workplace sexual harassment (International
Figure 12.5 Women’s earnings as a percent of men’s in 2010. Source: U.S. Bureau of Labor Statistics. Note: Data for Asians were note tabulated prior to 2000. © 2015 Cengage Learning
Women’s earnings as a percent of men’s, median usual weekly earnings of full-time wage and salary workers, in current dollars,
by race and ethnicity, 1980−2010 annual averages
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356 CHAPTER 12
Labour Organization, 2013). Victims are most often single or divorced young adult women (Zippel, 2006), but about 16 % of workplace cases that result in formal legal charges involve male victims (Equal Employment Opportunity Commission, 2010). Although the num- ber of formal complaints in the United States is declin- ing, it is unclear whether this is because of increased sensitivity and training by employers, reluctance of vic- tims to report for fear of losing their jobs during eco- nomically difficult times, or both.
What are the effects of being sexually harassed? As you might expect, research evidence clearly shows negative job-related, psychological, and physical health outcomes (Lim & Cortina, 2005).
Cultural differences in labeling behaviors as sexu- ally harassing are also important. Research comparing countries in the European Union reveals differences across these countries in terms of definitions and correc- tive action (Zippel, 2006). Unfortunately, little research has been done to identify what aspects of organizations foster harassment or to determine the impact of educa- tional programs aimed at addressing the problem.
In 1998, the U.S. Supreme Court (in Oncale v. Sundowner Offshore Services ) ruled the relevant laws also protect men. Thus, the standard by which sexual harassment is judged could now be said to be a “rea- sonable person” standard.
What can be done to provide people with safe work and learning environments, free from sexual harassment? Training in gender awareness is a common approach that often works, especially given gender differences exist in perceptions of behavior (Lindgren, 2007).
Age Discrimination. Another structural barrier to occupational development is age discrimination , that involves denying a job or promotion to someone solely on the basis of age . The U.S. Age Discrimination in Employ- ment Act of 1986 protects workers over age 40 . A law that brought together all of the anti-discrimination legislation in the United Kingdom, the Equality Act of 2010, includes a prohibition against age discrimi- nation, and more European countries are protecting middle-aged and older workers (Government Equali- ties Office, 2013; Lahey, 2010). These laws stipulate people must be hired based on their ability, not their age and cannot segregate or classify workers or other- wise denote their status on the basis of age.
Employment prospects for middle-aged people around the world are lower than for their younger counterparts (Lahey, 2010). Age discrimination toward those over age 45 is common in Hong Kong (Cheung, Kam, & Ngan, 2011), resulting in longer periods of unemployment, early retirement, or negative attitudes.
Age discrimination usually happens prior to or after interaction with human resources staff by other employees making the hiring decisions, and it can be covert (Lahey, 2010; Pillay, Kelly, & Tones, 2006). Employers can make certain types of physical or men- tal performance a job requirement and argue older workers cannot meet the standard prior to an inter- view. Or they can attempt to get rid of older workers by using retirement incentives. Supervisors’ stereotyped beliefs sometimes factor in performance evaluations for raises or promotions or in decisions about which employees are eligible for additional training (Chiu et al., 2001).
Adult Development In Action What are the key factors that interfere with people’s ability to create and manage their own careers?
12.3 Occupational Transitions LEARNING OBJECTIVES
Why do people change occupations? Is worrying about potential job loss a major
source of stress? How does job loss affect the amount of stress
experienced?
Fred has 32 years of service for an automobile manu- facturer. Over the years, more and more assembly-line jobs have been eliminated by new technology (including robots) and the export of manufacturing jobs to other countries. Although Fred has been assured his job is safe, he isn’t so sure. He worries he could be laid off at any time.
In the past, people like Fred commonly chose an occupation during young adulthood and stayed in it throughout their working years. Today, however, not many people have that option. Corporations have
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WORK, LEISURE, AND RETIREMENT 357
restructured so often employees now assume occu- pational changes are part of the career process. Such corporate actions mean people’s conceptions of work and career are in flux and losing one’s job no longer has only negative meanings (Haworth & Lewis, 2005).
Several factors have been identified as important in determining who will remain in an occupation and who will change. Some factors—such as whether the person likes the occupation—lead to self-initiated occupation changes.
However, other factors—such as obsolete skills and economic trends—may cause forced occupational changes. Continued improvement of robots has caused some auto industry workers to lose their jobs; corpora- tions send jobs overseas to increase profits; and eco- nomic recessions usually result in large-scale layoffs and high levels of unemployment.
Retraining Workers When you are hired into a specific job, you are selected because your employer believes you offer the best fit between the abilities you already have and those needed to perform the job. As most people can attest, though, the skills needed to perform a job usually change over time. Such changes may be based in the introduction of new technology, additional responsi- bilities, or promotion.
Unless a person’s skills are kept up-to-date, the out- come is likely to be either job loss or a career plateau (McCleese & Eby, 2006; Rose & Gordon, 2010). Career plateauing occurs when there is a lack of challenge in one’s job or promotional opportunity in the organiza- tion or when a person decides not to seek advancement . Research in Canada (Foster, Lonial, & Shastri, 2011), Asia (Lee, 2003), and Australia (Rose & Gordon, 2010) shows feeling one’s career has plateaued usually results in less organizational commitment, lower job satisfac- tion, and a greater tendency to leave. But attitudes can remain positive if it is only the lack of challenge and not a lack of promotion opportunity responsible for the plateauing (McCleese & Eby, 2006).
In cases of job loss or a career plateau, retraining may be an appropriate response. Around the world, large numbers of employees participate each year in programs and courses offered by their employer or by a college or university and aimed at improving existing skills or adding new job skills. For midcareer
employees, retraining might focus on how to advance in one’s occupation or how to find new career oppor- tunities—for example, through résumé preparation and career counseling. Increasingly, such programs are offered online in order to make them easier and more convenient for people to access (Githens & Sauer, 2010).
Many corporations, as well as community and technical colleges, offer retraining programs in a vari- ety of fields. Organizations that promote employee development typically promote in-house courses to improve employee skills. They may also offer tuition reimbursement programs for individuals who success- fully complete courses at colleges or universities.
The retraining of midcareer and older work- ers highlights the need for lifelong learning (Armstrong-Stassen & Templer, 2005; Sinnott, 1994). If corporations are to meet the challenges of a global economy, it is imperative they include retraining in their employee development programs. Such programs will improve people’s chances of advancement in their chosen occupations and also assist people in making successful transitions from one occupation to another.
Occupational Insecurity Over the past few decades, changing U.S. economic conditions (e.g., the move toward a global economy), changing demographics, and a global recession forced many people out of their jobs. Heavy manufacturing and support businesses (such as the steel, oil, and automotive industries) and farming were the hardest-hit sectors dur- ing the 1970s and 1980s. No one is immune. The Great Recession that began in 2008 put many middle- and upper-level corporate executives out of work worldwide.
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358 CHAPTER 12
As a result, many people feel insecure about their jobs. Economic downturns create significant levels of stress, especially when such downturns create massive job loss (Sinclair et al., 2010). Like Fred, the autoworker in the vignette, many worried workers have numerous years of dedicated service to a company. Unfortunately, people who worry about their jobs tend to have poorer physical and psychological well-being (McKee-Ryan et al., 2005). Anxiety about one’s job may result in negative attitudes about one’s employer or even about work in general, and in turn may result in diminished desire to be successful. Whether there is an actual basis for people’s feelings of job insecurity may not matter; sometimes what people think is true about their work situation is more important than what is actually the case. Just the possibility of losing one’s job can nega- tively affect physical and psychological health.
So how does the possibility of losing one’s job affect employees? Mantler and colleagues (2005) examined coping strategies for comparable samples of laid-off and employed high-technology workers. They found although unemployed participants reported higher levels of stress compared with employed par- ticipants, employment uncertainty mediated the asso- ciation between employment status and perceived stress. That is, people who believe their job is in jeopardy—even if it is not—show levels of stress simi- lar to unemployed participants. This result is due to differences in coping strategies. There are several ways people deal with stress, and two of the more common are emotion-focused coping and problem-focused coping. Some people focus on how the stressful situ- ation makes them feel, so they cope by making them- selves feel better about it. Others focus on the problem itself and do something to solve it. People who used emotional avoidance as a strategy reported higher lev- els of stress, particularly when they were fairly certain of the outcome. Thus, even people whose jobs aren’t really in jeopardy can report high levels of stress if they tend to use emotion-focused coping strategies.
Coping with Unemployment Losing one’s job can have enormous personal impact that can last a long time (Gabriel, Gray, & Goregaokar, 2013; Lin & Leung, 2010; McKee-Ryan et al., 2005). When U.S. unemployment rates hit 10.6 % in January 2010, millions of people could relate to these feelings.
When unemployment lasts and re-employment does not occur soon, unemployed people commonly expe- rience a wide variety of negative effects (Gabriel et al., 2013; Lin & Leung, 2010) that range from a decline in immune system functioning (Cohen et al., 2007) to decreases in well-being (Gabriel et al., 2013).
Coping with unemployment involves both finan- cial and personal issues. As noted in the Discovering Development feature, the financial support people receive varies across states and situations. Unemploy- ment compensation is typically much lower than one’s original salary, resulting in financial hardship and dif- ficult choices for individuals.
DISCOVERING DEVELOPMENT: WHAT UNEMPLOYMENT BENEFITS ARE AVAILABLE IN YOUR AREA? When a person loses his or her job, there may be cer- tain benefits available. Some of these are financial, such as weekly or monthly funds. Other benefits may be educational, such as job skills retraining. Find out what the range of benefits are in your area from gov- ernment and private organization sources. See what programs are available at your local colleges and universities to help people who have lost their jobs. Pay special attention to the length of time benefits last, and whether job retraining programs are free or have tuition attached to them. Then compile the list and discuss it in class.
In a comprehensive study of the effects of unem- ployment, McKee-Ryan and colleagues (2005) found several specific results from losing one’s job. Unem- ployed workers had significantly lower mental health, life satisfaction, marital or family satisfaction, and sub- jective physical health (how they perceive their health to be) than their employed counterparts. With reem- ployment, these negative effects disappear. Figure 12.6 shows physical and psychological health follow- ing job displacement is influenced by several factors (McKee-Ryan et al., 2005).
The effects of job loss vary with age, gender, and education. In the United States, middle-aged men are more vulnerable to negative effects than older or younger men—largely because they have greater finan- cial responsibilities than the other two groups—but
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WORK, LEISURE, AND RETIREMENT 359
women report more negative effects over time ( Bambra, 2010). Research in Spain indicates gender differ- ences in responding to job loss are complexly related to family responsibilities and social class (Artazcoz et al., 2004). Specifically, to the extent work is viewed as your expected contribution to the family, losing one’s job has a more substantial negative effect. Because this tends to be more the case for men than for women, it helps explain the gender differences. The higher one’s education levels, the less stress one typically feels immediately after losing a job, probably because higher education level usually result in faster re-employment (Mandemakers & Monden, 2013).
Because unemployment rates for many ethnic minority groups are substantially higher than for Euro- pean Americans (Bureau of Labor Statistics, 2013b), the effects of unemployment are experienced by a greater proportion of people in these groups. Cultural differences need to be considered in understanding the effects of unemployment (Grosso & Smith, 2012). Compared to European Americans, however, it usually takes minority workers longer to find another job.
How long you are unemployed also affects how people react. People who are unemployed for at least a year perceive their mental health significantly more negatively than either employed people or those who have removed themselves from the labor force (e.g.,
have stopped looking for work) (Pharr, Moonie, & Bungum, 2012). Those who lost their jobs involuntarily feel a loss of control over their “work” environment and feel less demand placed on them. Importantly, a rea- sonable amount of “demand” is critical to maintaining good health, whereas too little demand lowers health.
Research also offers some advice for adults who are trying to manage occupational transitions (Ebberwein, 2001):
Approach job loss with a healthy sense of urgency. Consider your next career move and what you
must do to achieve it, even if there are no pros- pects for it in sight.
Acknowledge and react to change as soon as it is evident.
Be cautious of stopgap employment. Identify a realistic goal and then list the steps you
must take to achieve it.
Additionally, the U.S. Department of Labor offers tips for job seekers, as do online services such as Linke- dIn that also provides networking groups. These steps may not guarantee you will find a new job quickly, but they will help create a better sense that you are in control.
Figure 12.6 Psychological and physical well-being after losing one’s job are affected by many variables. Source: From “Psychological and physical well-being during unemploy- ment: A meta-analytic study,” by F. McKee-Ryan, Z. Song, C. R. Wanberg, and A. J. Kinicki, in Journal of Applied Psychology, Vol. 90.
Cognitive appraisal Stress appraisal
Internal attribution Reemployment expectation
Coping strategies Job search effort
Problem-focused coping Emotion-focused coping
Psychological well-being Mental health
Life satisfaction Domain satisfaction
Physical well-being Subjective Objective
Work-role centrality
Human capital and demographics
Coping resources Personal
Social Financial
Time structure
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360 CHAPTER 12
Adult Development In Action How could the effects of losing a job be reduced?
nearly two-thirds of married and unmarried mothers with children under the age of 3 years are in the labor force (U.S. Department of Labor, 2013a).
Some women, though, grapple with the decision of whether they want to return to work. Surveys of mothers with preschool children reveal the motivation for returning to work tends to be related to financial need and how attached mothers are to their work. The amount of leave time a woman has matters; the pas- sage of the Family and Medical Leave Act in 1993 enti- tled workers to take unpaid time off to care for their dependents with the right to return to their jobs. This Act resulted in an increase in the number of women who returned to work at least part-time (Schott, 2010). Although working part-time work may seem appeal- ing, what matters more is whether mothers are work- ing hours close to what they consider ideal and are accommodating to their family’s needs (Kim, 2000). Perceptions of ideal working hours differ as a function of gender and life-cycle stage regarding children.
A concern for many women is whether stepping out of their occupations following childbirth will nega- tively affect their career paths. Indeed, evidence clearly indicates it does (Aisenbrey, Evertsson, & Grunow, 2009). Women in the United States are punished, even for short leaves. In women-friendly countries such as Sweden, long leaves typically result in a negative effect on upward career movement.
Often overlooked is the increasing number of workers who must also care for a parent or partner. Of women caring for parents or parents-in-law, more than 80 % provide an average of 23 hours per week of care and 70 % contribute money (Pierret, 2006). As we saw in Chapter 11 , providing this type of care takes a high toll through stress.
Whether assistance is needed for one’s children or parents, key factors in selecting an appropriate care site are quality of care, price, and hours of avail- ability (Helpguide.org, 2013; Mitchell & Messner, 2003–2004). Depending on one’s economic situation, it may not be possible to find affordable and quality care available when needed. In such cases, there may be no option but to drop out of the workforce or enlist the help of friends and family.
Dependent Care and Effects on Workers. Being responsible for dependent care has significant negative
12.4 Work and Family LEARNING OBJECTIVES
What are the issues faced by employed people who care for dependents?
How do partners view the division of household chores? What is work–family conflict, and how does it affect couples’ lives?
Jennifer, a 38-year-old sales clerk at a department store, feels her husband, Bill, doesn’t do his share of the housework or child care. Bill says real men don’t do housework and he’s really tired when he comes home from work. Jennifer thinks this isn’t fair, especially because she works as many hours as her husband.
One of the most difficult challenges facing adults like Jennifer is trying to balance the demands of occu- pation with the demands of family. Over the past few decades, the rapid increase in the number of families where both parents are employed has fundamentally changed how we view the relationship between work and family. This can even mean taking a young child to work as a way to deal with the pushes and pulls of being an employed parent. In roughly 60 % of two- parent households today, both adults work outside the home, a rate slightly lower than previous years due to the economic recession (Bureau of Labor Statistics, 2010d). Why? Families need the dual income to pay their bills and maintain a moderate standard of living.
We will see dual-earner couples with children experience both benefits and disadvantages. The stresses of living in this arrangement are substantial, and gender differences are clear—especially in the division of household chores.
The Dependent Care Dilemma Many employed adults must also provide care for dependent children or parents.
Employed Caregivers. Many mothers have no option but to return to work after the birth of a child. In fact,
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WORK, LEISURE, AND RETIREMENT 361
The most important single thing a company can do is allow the employee to leave work without penalty to tend to family needs (Lawton & Tulkin, 2010).
Research also indicates there may not be differ- ences for either mothers or their infants between work- based and nonwork-based child-care centers in terms of the mothers’ ease in transitioning back to work or the infants’ ability to settle into day care (Skouteris, McNaught, & Dissanayake, 2007).
It will be interesting to watch how these issues— especially flexible schedules—play out in the United States, where such practices are not yet common. A global study of parental leave, such as granted under the U.S. Family and Medical Leave Act, showed the more generous parental leave policies are, the lower the infant mortality rates, clearly indicating parental leave policies are a good thing (Ferrarini & Norström, 2010).
Juggling Multiple Roles When both members of a heterosexual couple with dependents are employed, who cleans the house, cooks the meals, and takes care of the children when they are ill? This question goes to the heart of the core dilemma of modern, dual-earner couples: How are household chores divided? How are work and family role conflicts handled?
Dividing Household Chores. Despite much media attention and claims of increased sharing in the duties, women still perform the lion’s share of house- work, regardless of employment status. As shown in Figure 12.7 , this is true globally (Ruppanner, 2010). This unequal division of labor causes the most argu- ments and the most unhappiness for dual-earner cou- ples. This is the case with Jennifer and Bill, the couple in the vignette; Jennifer does most of the housework.
Although women still do most of the household chores, things are getting a bit better. Women reduced the amount of time they spend on housework (espe- cially when they are employed) and men have increased the amount of time they spend on such tasks (Saginak & Saginak, 2005). The increased participation of men in these tasks is not all that it seems, however. Most of the increase is on weekends, involves specific tasks they agree to perform, and is largely unrelated to wom- en’s employment status. In short, the increase in men’s
effects on caregivers. Whether responsible for the care of an older parent or a child, women and men report negative effects on their work, higher levels of stress, and problems with coping (Neal & Hammer, 2006). Roxburgh (2002) introduced the notion parents of families dealing with time pressures feel much more stress; indeed, subsequent research clearly shows not only are stress levels higher, but “fast-forward fami- lies” also often deal with impacts on career advance- ment and physical and mental health consequences of this life style (Ochs & Kremer-Sadlik, 2013). Women’s careers are usually affected more negatively than men’s.
How can these negative effects be lessened? When women’s partners provide good support and women have average or high control over their jobs, employed mothers are significantly less distressed than employed nonmothers or mothers without support (Lovejoy & Stone, 2012; Moen & Roehling, 2005). Research focus- ing on single working mothers also shows those who have support from their families manage to figure out a balance between work and family obligations (Son & Bauer, 2010).
Dependent Care and Employer Responses. Employed parents with small children or dependent spouses/partners or parents are confronted with the difficult prospect of leaving them in the care of oth- ers. This is especially problematic when the usual care arrangement is unavailable. A growing need in the workplace is for backup care , that provides emergency care for dependent children or adults so the employee does not need to lose a day of work. Does providing a workplace care center or backup care make a differ- ence in terms of an employee’s feelings about work, absenteeism, and productivity?
There is no simple answer. Just making a child- care center available to employees does not necessarily reduce parents’ work–family conflict or their absentee- ism, particularly among younger employees (Connelly, Degraff, & Willis, 2004). A “family-friendly” company must also pay attention to the attitudes of their employ- ees and make sure the company provides broad-based support (Aryee, Chu, Kim, & Ryu, 2013; Moen & Roehling, 2005). The keys are how supervisors act and the number and type of benefits the company provides. Cross-cultural research in Korea confirms having a family-friendly supervisor matters (Aryee et al., 2013).
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362 CHAPTER 12
participation has not done much to lower women’s burdens around the house.
Men and women view the division of labor dif- ferently. Men are often most satisfied with an equi- table division of labor based on the number of hours spent, especially if the amount of time needed to per- form household tasks is relatively small. Women are often most satisfied when men are willing to perform women’s traditional chores (Saginak & Saginak, 2005). When ethnic minorities are studied, much the same is true concerning satisfaction.
Ethnic differences in the division of household labor are also apparent. In Mexican American families with husbands born in Mexico, men help more when family income is lower and their wives contribute a proportionately higher share of the household income (Pinto & Coltrane, 2009). Comparisons of Latino, African American, and European American men consistently show European American men help with the chores less than Latino or African American men (Omori & Smith, 2009).
Work–Family Conflict. When people have both occu- pations and children, they must figure out how to bal- ance the demands of each. These competing demands cause work–family conflict , the feeling of being pulled in multiple directions by incompatible demands from one’s job and one’s family .
Dual-earner couples must find a balance between their occupational and family roles. Because nearly 60 % of married couples with children consist of dual- earner households (Bureau of Labor Statistics, 2013b), how to divide the household chores and how to care
for the children have become increasingly important questions.
Many people believe in such cases, work and fam- ily roles influence each other: When things go badly at work, the family suffers, and when there are troubles at home, work suffers. That’s true, but the influence is not the same in each direction (Andreassi, 2007). Whether work influences family or vice versa is a complex func- tion of support resources, type of job, and a host of other issues (Saginak & Saginak, 2005). One key but often overlooked factor is whether the work schedules of both partners allow them to coordinate activities such as child care (van Klaveren, van den Brink, & van Praag, 2013).
Of course, it is important the partners negotiate agreeable arrangements of household and child-care tasks, but we’ve noted truly equitable divisions of labor are clearly the exception. Most U.S. households with heterosexual dual-worker couples still operate under a gender-segregated system: There are traditional chores for men and women. These important tasks must be performed to keep homes safe, clean, and sanitary, and these tasks also take time. The important point for women is not how much time is spent perform- ing household chores so much as which tasks are per- formed. What bothers wives the most is when their husbands are unwilling to do “women’s work.” Men may mow the lawn, wash the car, and even cook, but they are much less likely to vacuum, scrub the toilet, or change the baby’s diaper.
So how and when will things change? An impor- tant step would be to talk about these issues with your partner. Keep communication lines open all the time, and let your partner know if something is bothering
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Figure 12.7 Women spend much more time on household chores than men. Source: Data from “Cross-national reports of housework: An investigation of the gender empowerment measure,” by L. E. Ruppanner, in Social Science Research, Vol. 19, Table 1, p. 968. Copyright © Elsevier 2010.
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WORK, LEISURE, AND RETIREMENT 363
you. Teaching your children men and women are equally responsible for household chores will also help end the problem. Only by creating true gender equality—without differentiating among household tasks—will this unfair division of labor be ended.
Understanding work–family conflict requires tak- ing a life-stage approach to the issue (Blanchard-Fields, Baldi, & Constantin, 2004). Several studies have found the highest conflict between the competing demands of work and family occurs during the peak parenting years, when there are at least two preschool children in the home. Inter-role conflict diminishes in later life stages, especially when the quality of the marriage is high.
A comprehensive review of the research on the experience of employed mothers supports this con- clusion (Edwards, 2012). How juggling the demands of housework and child care affect women depends on the complex interplay among the age of the chil- dren, the point in career development and advance- ment the woman is, and her own developmental phase. The combination of challenges that any one of these reflects changes over time. Because all of these factors are dynamic, how they help or hinder a woman in her career changes over time.
In addition to having impacts on each individual, dual-earner couples often have difficulty finding time for each other, especially if both work long hours. The amount of time together is not necessarily the most important issue; as long as the time is spent in shared activities such as eating, playing, and conversing, cou- ples tend to be happy (Ochs & Kremer-Sadlik, 2013). When both partners are employed, getting all of the schedules to work together smoothly can be a major challenge. However, these joint activities are impor- tant for creating and sustaining strong relations among family members. Unfortunately, many couples find by the time they have an opportunity to be alone together, they are too tired to make the most of it.
The issues faced by dual-earner couples are global: burnout from the dual demands of work and parent- ing is more likely to affect women across many cul- tures (Aryee et al, 2013; van Klaveren et al., Spector et al., 2005). Japanese career women’s job satisfaction declines, and turnover becomes more likely, to the extent they have high work–family conflict (Honda- Howard & Homma, 2001). Research comparing sources of work–family conflict in the United States
and China reveals when work demands do not differ, work pressure is a significant source of work–family conflict in both countries (Yang et al., 2000).
So exactly what effects do family matters have on work performance and vice versa? Evidence suggests work–family conflict is a major source of stress in cou- ples’ lives. In general, women feel the work-to-family spillover to a greater extent than men, but both men and women feel the pressure (Edwards, 2012; Saginak & Saginak, 2005).
The work-family conflict described here are argu- ably worst for couples in the United States because Americans work more hours with fewer vacation days than any other developed country (Frase & Gornick, 2013). However, couples can work together to help mitigate the stress. Most important, they can negoti- ate schedules around work commitments throughout their careers, taking other factors such as child care and additional time demands into account (van Wan- rooy, 2013). These negotiations should include discus- sion of such joint activities as meals and other family activities, too (Ochs and Kremer-Sadlik, 2013).
Adult Development In Action What are the stresses and ways to deal with them facing dual-earner couples?
12.5 Leisure Activities LEARNING OBJECTIVES
What activities are leisure activities? How do people choose among them?
What changes in leisure activities occur with age? What do people derive from leisure activities?
Claude is a 55-year-old electrician who has enjoyed outdoor activities his whole life. From the time he was a boy he fished and water-skied in the calm inlets of coastal Florida. Although he doesn’t compete in slalom races any more, Claude still skis regularly and participates in fish- ing competitions every chance he gets.
Adults do not work every waking moment of their lives. As each of us knows, we need to relax sometimes and engage in leisure activities. Intuitively, leisure
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364 CHAPTER 12
consists of activities not associated with work. Leisure is discretionary activity that includes simple relaxation, activities for enjoyment, and creative pursuits . As you might expect, men and women differ in their views of leisure, as do people in different ethnic and age groups (van der Pas & Koopman-Boyden, 2010).
A major issue with leisure is simply finding the time. Young and middle-aged adults must fit leisure into an already busy schedule, so leisure becomes another component in our overall time management problem (Corbett & Hilty, 2006).
Types of Leisure Activities Leisure can include virtually any activity. To organize the options, researchers classified leisure activities into several categories. Jopp and Hertzog (2010) developed an empirically based set of categories that includes a wide variety of activities: physical (e.g., lifting weights, backpacking, jogging), crafts (e.g., woodworking, household repairs), games (e.g., board/online games, puzzles, card games), watching TV, social-private (e.g., going out with a friend, visiting relatives, going out to dinner), social-public (e.g., attending a club meeting, volunteering), religious (e.g., attending a religious ser- vice, praying), travel (e.g., travel abroad, travel out of town), experiential (e.g., collect stamps, read for lei- sure, gardening, knitting), developmental (e.g., read as part of a job, study a foreign language, attend public lecture), and technology use (e.g., photography, use computer software, play an instrument).
More complete measures of leisure activities not only provide better understanding of how adults spend their time, but can help in clinical settings. Declines in the frequency of leisure activities is associated with depression (Schwerdtfeger & Friedrich-Mei, 2009) and with a later diagnosis of dementia (Hertzog, Kramer, Wilson, & Lindenberger, 2009). Monitoring changes in leisure activity levels during and after intervention programs can provide better outcomes assessments of these interventions.
Given the wide range of options, how do people pick their leisure activities? Apparently, each of us has a leisure repertoire, a personal library of intrinsically motivated activities we do regularly and we take with us into retire- ment (Nimrod, 2007a,b). The activities in our repertoire are determined by two things: perceived competence (how good we think we are at the activity compared to
other people our age) and psychological comfort (how well we meet our personal goals for performance).
A study of French adults revealed, as for occupa- tions, personality factors are related to one’s choice of leisure activities (Gaudron & Vautier, 2007). Other factors are important as well: income, interest, health, abilities, transportation, education, and social charac- teristics. Some leisure activities, such as downhill ski- ing, are relatively expensive and require transportation and reasonably good health and physical coordination for maximum enjoyment. In contrast, reading requires minimal finances (if one uses a public library) and is far less physically demanding. Women in all ethnic groups tend to participate less in leisure activities that involve physical activity (Eyler et al., 2002).
The use of computer technology in leisure activi- ties has increased dramatically (Bryce, 2001). Most usage involves e-mail, Facebook, Twitter, or other social networking tools for such activities as keeping in touch with family and friends, pursuing hobbies, and lifelong learning. Computer gaming on the Web has also increased among adult players.
Developmental Changes in Leisure Cross-sectional studies report age differences in leisure activities. Young adults participate in a greater range of activities than middle-aged adults. Furthermore, young adults prefer intense leisure activities, such as scuba diving and hang gliding. In contrast, middle- aged adults focus more on home- and family-oriented activities. In later middle age, they spend less of their leisure time in strenuous physical activities and more
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WORK, LEISURE, AND RETIREMENT 365
in sedentary activities such as reading and watching television (van der Pas & Koopman-Boyden, 2010).
Longitudinal studies of changes in individuals’ leisure activities over time show considerable stability over reasonably long periods, and that level of activity in young adulthood predicts activity level later in life (Hillsdon, Brunner, Guralnik, & Marmot, 2005; Patel et al., 2006). Claude, the 55 -year-old in the vignette who likes to fish and ski, is a good example of this overall trend. As Claude demonstrates, frequent participation in particular leisure activities during childhood tends to continue into adulthood. Similar findings hold for the pre- and postretirement years. Apparently, one’s pref- erences for certain types of leisure activities are estab- lished early in life; they tend to change over the life span primarily in terms of how physically intense they are.
Consequences of Leisure Activities What do people gain from participating in leisure activ- ities? Researchers have long known involvement in lei- sure activities is related to well-being (Warr, Butcher, & Robertson, 2004). This relation holds in other coun- tries, such as China, as well (Dai, Zhang, & Li, 2013). Research shows participating in leisure activities helps promote better mental health in women (Ponde & Santana, 2000), such as when they use family-based leisure as a means to cope during their partner’s mili- tary deployment (Werner & Shannon, 2013), and buf- fers the effects of stress and negative life events. It even helps lower the risk of mortality (Talbot et al., 2007).
Studies show leisure activities provide an excellent forum for the interaction of biological, psychologi- cal, and sociocultural forces (Kleiber, Hutchinson, & Williams, 2002; Kleiber, 2013). Leisure activities are a good way to deal with stress, which—as we have seen— has significant biological effects. This is especially true for unforeseen negative events (Janoff-Bulman & Berger, 2000). Psychologically, leisure activities have been well documented as one of the primary coping mechanisms people use (Patry, Blanchard, & Mask, 2007). How people cope by using leisure varies across cultures depending on the various types of activities that are permissible and available. Likewise, leisure activities vary across social class; basketball is one activity that cuts across class because it is inexpensive, whereas downhill skiing is more associated with people who can afford to travel to ski resorts and pay the fees.
How do leisure activities provide protection against stress? Kleiber and colleagues (2002; 2013) offer four ways leisure activities serve as a buffer against negative life events:
Leisure activities distract us from negative life events.
Leisure activities generate optimism about the future because they are pleasant.
Leisure activities connect us to our personal past by allowing us to participate in the same activities over much of our lives.
Leisure activities can be used as vehicles for per- sonal transformation.
Whether the negative life events we experience are personal, such as the loss of a loved one, or societal, such as a terrorist attack, leisure activities are a com- mon and effective way to deal with them. They truly represent the confluence of biopsychosocial forces and are effective at any point in the life cycle.
Participating with others in leisure activities may also strengthen feelings of attachment to one’s partner, friends, and family (Carnelley & Ruscher, 2000). Adults use leisure as a way to explore interpersonal relation- ships or to seek social approval. In fact, research indi- cates marital satisfaction is linked with leisure time; marital satisfaction is even helped when couples spend some leisure time with others in addition to spending it just as a couple (Zabriskie & Kay, 2013). But there’s no doubt couples who play together are happier (John- son, Zabriskie, & Hill, 2006).
What if leisure activities are pursued seriously? In some cases, people create leisure–family conflict by engaging in leisure activities to extremes (Heo, Lee, McCormick, & Pedersen, 2010). Individuals who are serious about participating in specific leisure activities may experience “flow” or being in the “zone.” When things get serious, problems may occur. Only when there is support from others for such extreme involve- ment are problems avoided. Professional quilters felt much more valued when family members were sup- portive (Stalp & Conti, 2011). As in most things, mod- eration in leisure activities is probably best, unless you know you have excellent support.
You have probably heard the saying “no vaca- tion goes unpunished.” It appears to be true, and the
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366 CHAPTER 12
trouble is not just afterward. Research shows pre- vacation workload is associated with lower health and well-being for both men and women, and pre-vacation homeload (extra work that needs to be done at home) has the same negative effect for women (Nawijn, de Bloom, & Geurts, 2013).
Once on vacation, it matters what you do. If you detach from work, enjoy the activities during vacation, and engage in conversation with your partner, then the vacation can improve health and well-being, even after you return home (de Bloom, Geurts, & Kompier, 2012). However, workers report high postvacation workloads eliminate most of the positive effects of a vacation within about a week (de Bloom, Geurts, Taris, Sonnentag, de Weerth, & Kompier, 2010). Restful vacations do not prevent declines in mood or in sleep due to one’s postvacation workload.
One frequently overlooked outcome of leisure activity is social acceptance. For persons with dis- abilities, this is a particularly important consideration (Choi, Johnson, & Kriewitz, 2013). There is a positive connection between frequency of leisure activities and positive identity, social acceptance, friendship devel- opment, and acceptance of differences. These findings highlight the importance of designing inclusive leisure activity programs.
have enough to pay the bills. Marcus is largely happy with retirement, and he stays in touch with his friends. He thinks maybe he’s a little strange, though, since he has heard retirees are supposed to be isolated and lonely.
Did you know that until 1934, when a railroad union sponsored a bill promoting mandatory retire- ment, and 1935, when Social Security was inaugu- rated, retirement was not even considered a possibility by most Americans like Marcus (McClinton, 2010; Sargent, Lee, Martin, & Zikic, 2013)? Only since World War II has there been a substantial number of retired people in the United States (McClinton, 2010). Although we take retirement for granted, economic downturns have a major disruptive effect on people’s retirement decisions and plans—after declining for decades, the number of people over age 65 still in the workforce has increased significantly (Sterns & Chang, 2010). As more people retire and take advantage of longer lives, a significant social challenge is created regarding how to fund retiree benefits and view older adults who are still active (Bengtsson & Scott, 2011; McClinton, 2010; Tsao, 2004).
After having one or several careers across adult- hood, many older adults find themselves question- ing whether they want to continue in that line of work anymore, or find themselves being forced to go through that questioning because they lost their jobs. This period of questioning and potential exploration enables people to think about their options: retiring, looking for work in the same of a different field, vol- unteering, or some combination of all of these. With the movement of the baby boom generation into old age, increasing numbers of these adults are redefining what “retirement” and “work” mean in late life. Realiz- ing these generational shifts reflect important changes in how people view the latter part of one’s working life, AARP launched the Life Reimagined tool that assists people in finding their path, including reawakening long-dormant interests.
As we consider retirement and other options in late life, keep in mind the world is changing, resulting in increased options and the likelihood more older adults will continue in the labor force by choice and necessity.
What Does Being Retired Mean? Retirement means different things to men and women, and to people in different ethnic groups (Loretto &
Adult Development In Action What effect does leisure have on adult development and aging?
12.6 Retirement and Work in Late Life LEARNING OBJECTIVES
What does being retired mean? Why do people retire? How satisfied are retired people? What employment and volunteer opportunities
are there for older adults?
Marcus is a 77-year-old retired construction worker who labored hard all of his life. He managed to save a little money, but he and his wife live primarily off of his monthly Social Security checks. Though not rich, they
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WORK, LEISURE, AND RETIREMENT 367
Vickerstaff, 2013; Luborsky & LeBlanc, 2003; McClin- ton, 2010). It has also taken on new and different meanings since the beginning of the Great Recession in 2008 because of the abrupt change in people’s plan- ning and expectations as a result of the loss of savings or pensions (Sargent et al., 2013).
Part of the reason it is difficult to define retire- ment precisely is the decision to retire involves the loss of occupational identity and not what people may add to their lives. What people do for a living is a major part of their identity; we introduce ourselves as postal workers, teachers, builders, or nurses as a way to tell people something about ourselves. Not doing those jobs any more means we either put that aspect of our lives in the past tense—“I used to work as a manager at the Hilton”—or say nothing at all. Loss of this aspect of ourselves can be difficult to face, so some look for a label other than “retired” to describe themselves.
That’s why researchers view retirement as another one of many transitions people experience in life (Sargent et al., 2013; Schlossberg, 2004; Sterns & Chang, 2010). This view makes retirement a complex process where people withdraw from full-time partici- pation in an occupation (Sargent et al., 2013), recogniz- ing there are many pathways to this end (Everingham, Warner-Smith, & Byles, 2007; Sargent et al., 2013).
Why Do People Retire? Provided they have good health, more workers retire by choice than for any other reason (Ekerdt, 2010; McClinton, 2010; Sterns & Chang, 2010), although economic conditions both personally and in society also have powerful effects (Hairault, Langot, & Zylberberg, 2012). Individuals usually retire when they feel financially secure after considering projected income from Social Security, pensions and other structured retirement programs, and personal savings. Of course, some people are forced to retire because of health problems or because they lose their jobs. As corporations downsize during economic downturns or after corporate mergers, some older workers accept buyout packages involving supplemental payments if they retire. Others are permanently furloughed, laid off, or dismissed.
The decision to retire is influenced by one’s occu- pational history and goal expectations (Ekerdt, 2010;
Hairault et al., 2012; McClinton, 2010; Sargent et al., 2013). Whether people perceive they will achieve their personal goals through work or retirement influences the decision to retire and its connection with health and disability.
The rude awakening many people received during the Great Recession was the best made plans are only as good as external factors allow them to be, especially when it comes to financial savings and pensions. Many people lost much, and sometimes all of these financial packages as the value of stocks plummeted and com- panies eliminated pension plans. Consequently, many people were forced to delay their retirement until they had the financial resources to do so, or to continue working part time when they had not planned to do so to supplement their income. Research shows 44 % of people over age 55 in 2013 now think they will retire beyond age 66 , compared to 29 % in 2003 (Employee Benefits Research Institute, 2013).
Additionally, many people do not have adequate savings for retirement. As you can see in Table 12.1 , most people have not saved nearly what they need (Employee Benefits Research Institute, 2013). There has also been a decline in the confidence people have in their savings being adequate.
Note: Figures do not include the value of the primary residence or defined benefit plans
Source: Employee Benefits Research Institute. (2013). 2013 Retirement Confidence Survey. (Figure 3).
Table 12.1
Reported total savings and investments, among those providing a response
All Workers
Ages 25–34
Ages 35–44
Ages 45–54
Ages 55+
Less than $ 10,000
46 % 60 % 46 % 40 % 36 %
$ 10,000 – $ 24,999
11 15 12 11 7
$ 25,000 – $ 49,999
9 9 11 6 9
$ 50,000 – $ 99,999
10 8 10 13 8
$ 100,000 – $ 249,999
12 7 13 14 18
$ 250,000 or more
12 2 8 16 24
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368 CHAPTER 12
How much do you need to have in savings to be comfortable in retirement? A decent rule of thumb is to plan for between 65 % and 75 % of your current income and that usually means having savings equal to about 11 times your final salary in addition to expected income from Social Security (Aon, 2013). This figure takes into account typical medical expenses. The bot- tom line is longer life expectancies have added to the amount of money you will need in retirement—and that amount is usually much greater than people think.
Gender and Ethnic Differences. Women’s experience of retiring can be quite different from men’s (Everingham et al., 2007; Frye, 2008; Loretto & Vickerstaff, 2013). Women may enter the workforce after they have stayed home and raised children and in general have more dis- continuous work histories; also, having fewer financial resources may affect women’s decisions to retire. Women also tend to spend less time planning their retirement (Jacobs-Lawson, Hershey, & Neukam, 2004).
For women who were never employed outside the home, the process of retirement is especially unclear (Gardiner et al., 2007; Loretto & Vickerstaff, 2013). Because they were not paid for all of their work raising children and caring for the home, it is rare for them to have their own pensions or other sources of income in retirement. Additionally, the work they have always done in caring for the home continues, often nearly uninterrupted.
There has not been much research examining the process of retirement as a function of ethnicity. African American older adults are likely to continue working beyond age 65 (Troutman et al., 2011). However, there are no ethnic-based differences in health outcomes between African American women and men following retirement (Curl, 2007).
Adjustment to Retirement How do people who go through the process of retire- ment adjust to it? Researchers agree on one point: New patterns of personal involvement must be devel- oped in the context of changing roles and lifestyles in retirement (Potočnik, Tordera, & Peiró, 2013). People’s adjustment to retirement evolves over time as a result of complex interrelations involving physical health, financial status, to the degree their retirement was vol- untary, and feelings of personal control (Ekerdt, 2010).
How do most people fare? As long as people have financial security, health, a supportive network of relatives and friends, and an internally driven sense of motivation, they report feeling good about being retired (Ekerdt, 2010; Hershey & Henkens, in press; Potočnik et al., 2013).
One widely held view is being retired has negative effects on health. Research findings show the relation between health and retirement is complex. On the one hand, there is no evidence voluntary retirement has immediate negative effects on health (Hershey & Henkens, in press; Weymouth, 2005). In contrast, there is ample evidence being forced to retire is cor- related with significantly poorer physical and mental health (Donahue, 2007; Hershey & Henkens, in press). Health issues are also a major predictor of when a per- son retires, as a longitudinal study in England showed (Rice et al., 2010).
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WORK, LEISURE, AND RETIREMENT 369
Employment and Volunteering Retirement is an important life transition, one best understood through a life-course perspective that takes other aspects of one’s life, such as one’s mari- tal relationship, into account (Wickrama, O’Neal, & Lorenz, 2013). This life change means retirees must look for ways to adapt to new routines and patterns, while maintaining social integration and being active in various ways (e.g., friendship networks, community engagement).
Working in Late Life. For an increasing number of people, especially for those whose retirement savings either took a significant drop or disappeared during the Great Recession, “retirement” involves working at least part-time. Employment for them is a financial necessity to make ends meet, especially for those whose entire income would consist only of Social Security benefits. For others, the need to stay employed at least part-time represents a way to stay involved and as an income supplement.
As you can see in Figure 12.8 , the number of adults age 65 and over who are in the labor force nearly dou- bled between 2003 and 2013. Note also the trend has been consistently upward, indicating the forces keep- ing older adults in the labor force have been acting for many years (Bureau of Labor Statistics, 2013c).
Overall, labor force participation of older adults in the United States and other developed countries has been increasing most rapidly among women (Sterns & Chang, 2010). This is due mostly to more women being
in the labor force across adulthood than in decades past and more older women being single and needing the income. Most older adults are employed part-time, and this proportion is increasing because of the loss of full-time jobs in the Great Recession.
Older workers face many challenges, not the least of which are ageism and discrimination (Jackson, 2013). Employers may believe older workers are less capable, and there is some evidence this translates into lower likelihood of getting a job interview compared to younger or middle-aged workers, all other things being equal. Despite the fact age discrimination laws in the United States protect people over age 40 , such barriers are still widespread.
The relationship between age and job perfor- mance is extremely complex (Sterns & Chang, 2010). This is because it depends a great deal on the kind of job one is considering, such as one that involves a great deal of physical exertion or one involving a great deal of expertise and experience. In general, older work- ers show more reliability (e.g., showing up on time for work), organizational loyalty, and safety-related behavior.
How have companies adapted to having more older workers? One example is BMW, that changed a number of things in its automobile assembly plants to meet the needs of older workers better (de Pommereau, 2012). BMW provides physical trainers on the factory floor, laid new, softer floors, chairs that rise up and down to make tasks easier, larger print fonts on com- puter screens, and providing special shoes.
Figure 12.8 Number of adults aged 65 and over in the labor force. Source: Bureau of Labor Statistics. (2013c). Labor force statistics from the Current Population Survey.
5,000,000
6,000,000
7,000,000
01/0401/03 01/05 01/06 01/07 01/08 Month
01/09 01/10 01/11 01/12 01/13
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370 CHAPTER 12
The trend for companies to employ older work- ers, especially on a part-time basis, is likely to con- tinue because it is a good option of companies (Beck, 2013). Some companies find they need the expertise older workers bring, and the flexibility of older work- ers in terms of hours and the type of benefits they need (or do not need) often make it less expensive. Conse- quently, “retirement” is likely to continue to evolve as a concept, and likely to include some aspect of employ- ment well into late life.
Volunteering. The past few decades have witnessed a rapid growth of organizations devoted to offering such opportunities to retirees. Groups at the local commu- nity level, including senior centers and clubs, promote the notion of lifelong learning and keep older adults cognitively active. Many also offer travel opportunities specifically designed for active older adults.
Healthy, active retired adults also maintain com- munity ties by volunteering (Kleiber, 2013). Older adults report they volunteer for many reasons that benefit their well-being (Greenfield & Marks, 2005): to provide service to others, to maintain social inter- actions and improve their communities, and to keep active. Why do so many people volunteer?
Several factors are responsible (Tang, Morrow- Howell, & Choi, 2010): developing a new aspect of the self, finding a personal sense of purpose, desire to share one’s skills and expertise, a redefinition of the nature and merits of volunteer work, a more highly educated and healthy population of older adults, and greatly expanded opportunities for people to become involved in volunteer work that they enjoy. Research in New Zea- land documents older adults find volunteering enables them to give back to their local communities (Wiles & Jayasinha, 2013). Brown and colleagues (2011) argue volunteerism offers a way for society to tap into the vast resources older adults offer.
There is also evidence the expectations of people who volunteer in retirement are changing. Seaman (2012) notes women in the leading edge of the baby boom generation are interested in volunteering for personal, rather than purely altruistic reasons and do so on their own terms. They are not as willing as were volunteers in previous generations to serve on
time consuming boards and engage in fundraising. As a result, organizations that rely on volunteers need to be in touch with the concerns and motivations of their pool of volunteers.
Adult Development In Action What cognitive and physical factors influence the decision to retire?
SOCIAL POLICY IMPLICATIONS In the United States, the first law regarding pay equity was passed by Congress in 1963. Forty-six years later in 2009, President Obama signed the Lilly Led- better Fair Pay Act, showing clearly the problem of pay inequity still exists. In their comprehensive and insightful analysis of the continuing gap between men’s and women’s paychecks for the same work, Dey and Hill (2007) make a clear case that much needs to be done, and now.
Why? Consider this: Only one year out of col- lege, a woman earns on average about $ 0.80 for every $ 1.00 a male college graduate earns. A decade later, she’s down to about $ 0.69 . This is even after controlling for such important variables as occupa- tion, hours worked, parenthood, and other factors associated with pay.
What if women choose a college major associ- ated with high-paying jobs, such as those in science, technology, engineering, and mathematics? Will that help reduce the pay differential? No. Choosing a tra- ditionally male-dominated major will not solve the problem alone. Women in mathematics occupations earn only about $ 0.76 for every $ 1.00 a male math- ematics graduate earns.
A woman is also significantly disadvantaged when it comes to the division of labor at home if she is married to or living with a man. Despite decades of effort in getting men to do more of the housework and child-care tasks, little has changed in terms of the amount of time men actually spend on these tasks. In effect, this means women have two careers, one in the workplace and the other at home. If a college- educated woman stays at home to care for a child or parent, then her return to the workforce will be at a lower salary than it would have been otherwise.
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WORK, LEISURE, AND RETIREMENT 371
Summary 12.1 Occupational Selection and Development
How do people view work? Although most people work for money, other rea-
sons are highly variable.
How do people choose their occupations? Holland’s theory is based on the idea people
choose occupations to optimize the fit between their individual traits and their occupational inter- ests. Six personality types, representing different combinations of these, have been identified. Sup- port for these types has been found in several studies.
Social cognitive career theory emphasizes how peo- ple choose careers is also influenced by what they think they can do and how well they can do it, as well as how motivated they are to pursue a career.
What factors influence occupational development? Reality shock is the realization one’s expectations
about an occupation are different from what one actually experiences. Reality shock is common among young workers.
Few differences exist across generations in terms of their occupational expectations.
A mentor or developmental coach is a co-worker who teaches a new employee the unwritten rules and fosters occupational development. Mentor– protégé relationships, like other relationships, develop through stages over time.
What is the relationship between job satisfaction and age?
Older workers report higher job satisfaction than younger workers, but this may be partly due to self-selection; unhappy workers may quit. Other reasons include intrinsic satisfaction, good fit, lower importance of work, finding nonwork diversions, and life-cycle factors.
Alienation and burnout are important consid- erations in understanding job satisfaction. Both involve significant stress for workers.
Vallerand’s Passion Model proposes people develop a passion toward enjoyable activities that are incorporated into identity. Obsessive passion hap- pens when people experience an uncontrollable urge to engage in the activity; harmonious passion
results when individuals freely accept the activity as important for them without any contingencies attached to it.
12.2 Gender, Ethnicity, and Discrimination Issues
How do women’s and men’s occupational expectations differ? How are people viewed when they enter occupations that are not traditional for their gender?
Boys and girls are socialized differently for work, and their occupational choices are affected as a result. Women choose nontraditional occupations for many reasons, including expectations and per- sonal feelings. Women in such occupations are still viewed more negatively than men in the same occupations.
What factors are related to women’s occupational development?
Women leave well-paid occupations for many rea- sons, including family obligations and workplace environment. Women who continue to work full- time have adequate child care and look for ways to further their occupational development.
The glass ceiling, that limits women’s occupational attainment, and the glass cliff, that puts women leaders in a precarious position, affect how often women achieve top executive positions and how successful women leaders are.
What factors affect ethnic minority workers’ occupational experiences and occupational development?
Vocational identity and vocational goals vary in dif- ferent ethnic groups. Whether an organization is sensitive to ethnicity issues is a strong predictor of satisfaction among ethnic minority employees.
What types of bias and discrimination hinder the occupational development of women and ethnic minority workers?
Gender bias remains the chief barrier to women’s occupational development. In many cases, this operates as a glass ceiling. Pay inequity is also a problem; women are often paid less than what men earn in similar jobs.
Sexual harassment is a problem in the workplace. Current criteria for judging harassment are based on the “reasonable person” standard. Denying employment to anyone over 40 because of age is age discrimination.
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372 CHAPTER 12
12.3 Occupational Transitions
Why do people change occupations? Important reasons people change occupations
include personality, obsolescence, and economic trends.
To adapt to the effects of aglobal economy and a gain workforce, many corporations are providing retraining opportunities for workers. Retraining is especially important in cases of outdated skills and career plateauing.
Is worrying about potential job loss a major source of stress?
Occupational insecurity is a growing problem. Fear that one may lose one’s job is a better predictor of anxiety than the actual likelihood of job loss.
How does job loss affect the amount of stress experienced?
Job loss is a traumatic event that can affect every aspect of a person’s life. Degree of financial distress and the extent of attachment to the job are the best predictors of distress.
12.4 Work and Family
What are the issues faced by employed people who care for dependents?
Caring for children or aging parents creates dilem- mas for workers. Whether a woman returns to work after having a child depends largely on how attached she is to her work. Simply providing child care on-site does not always result in higher job satisfaction. A more important factor is the degree that supervisors are sympathetic.
How do partners view the division of household chores? What is work–family conflict? How does it affect couples’ lives?
Although women have reduced the amount of time they spend on household tasks over the past two decades, they still do most of the work. European American men are less likely than either African American or Latino American men to help with traditionally female household tasks.
Flexible work schedules and the number of chil- dren are important factors in role conflict. Recent evidence shows work stress has a much greater impact on family life than family stress has on work performance. Some women pay a high personal price for having careers.
12.5 Leisure Activities
What activities are leisure activities? Leisure activities can be simple relaxation, activities
for enjoyment, or creative pursuits. Views of leisure activities varies by gender, ethnicity, and age.
What changes in leisure activities occur with age? As people grow older, they tend to engage in lei-
sure activities that are less strenuous and more family-oriented. Leisure preferences in adulthood reflect those earlier in life.
What do people derive from leisure activities? Leisure activities enhance well-being and can ben-
efit all aspects of people’s lives.
12.6 Retirement and Work in Late Life
What does being retired mean? Retirement is a complex process by which people
withdraw from full-time employment. There is no adequate, single definition for all ethnic groups. People’s decisions to retire involve several factors, including eligibility for certain social programs, and personal financial and health resources.
Why do people retire? People generally retire because they choose to, but
many people are forced to retire because of job loss or serious health problems.
How satisfied are people with retirement? Retirement is an important life transition. Most
people are satisfied with retirement. Many retired people maintain their health, friendship networks, and activity levels.
What employment and volunteer opportunities are there for older adults?
Increasingly, people continue some level of partici- pation in the labor force during retirement, usu- ally for financial reasons. Labor force participation among older adults continues to increase. Volun- teer work is another way of achieving this.
Review Questions 12.1 Occupational Selection and Development
What are occupational priorities and how do they change over time?
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WORK, LEISURE, AND RETIREMENT 373
How is work changing as a result of the global economy?
Briefly describe social cognitive career theory (SCCT).
How is reality shock a developmental concept? What is a mentor? What role does a mentor play in
occupational development? How does the mentor– protégé relationship change over time?
What is the developmental course of job satisfac- tion? What factors influence job satisfaction?
What are alienation and burnout? How are they related to job satisfaction?
Briefly describe Vallerand’s Passion Model.
12.2 Gender, Ethnicity, and Discrimination What gender differences have been identified
relating to occupational choice? How are men and women socialized differently in ways that influence occupational opportunities?
How are women in nontraditional occupations per- ceived?
What are the major barriers to women’s occupa- tional development?
What major barriers to occupational development are related to ethnicity?
How are sex discrimination and the glass ceiling/ glass cliff related?
What are the structural barriers ethnic minorities face in occupational settings?
How is sexual harassment defined? What is age discrimination and how does it oper-
ate?
12.3 Occupational Transitions What are the major reasons why people change
occupations? Why is retraining workers important? What effects do people report after losing their
jobs?
12.4 Work and Family What factors are important in dependent care for
employees? How do dual-earner couples balance multiple roles
and deal with role conflict?
What important factors contribute to work-family conflict? What other occupational development effects occur?
12.5 Leisure Activities What are the major reasons people engage in lei-
sure activities? What benefits occur? What kinds of leisure activities do people perform? How do leisure activities change over the life span?
12.6 Retirement and Work in Late Life In what ways can retirement be viewed? How may
the definition of retirement change in the next sev- eral years?
What are the main predictors of the decision to retire?
How do people adjust to being retired? What factors influence decisions to continue work-
ing or volunteering in retirement?
INTEGRATING CONCEPTS IN DEVELOPMENT What role do personal relationships play in one’s
work, leisure, and retirement? How does cognitive development and personality
influence work roles? What implications are there for the removal of
mandatory retirement in terms of normal cognitive changes with age?
KEY TERMS age discrimination Denying a job or a promotion to a person solely on the basis of age.
alienation Situation in which workers feel they are doing is meaningless and their efforts are devalued, or when they do not see the connection between what they do and the final product.
backup care Emergency care for dependent children or adults so the employee does not need to lose a day of work.
burnout The depletion of a person’s energy and motivation, the loss of occupational idealism, and the feeling of being exploited.
Career construction theory Posits people build careers through their own actions that result from the
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374 CHAPTER 12
interface of their own personal characteristics and the social context.
career plateauing Situation occurring when there is a lack of challenge in the job or promotional opportunity in the organization or when a person decides not to seek advancement.
gender discrimination Denying a job to someone solely on the basis of whether the person is a man or a woman.
glass ceiling The level to which a woman may rise in an organization but beyond which they may not go.
glass cliff A situation in which a woman’s leadership position in an organization is precarious.
job satisfaction The positive feeling that results from an appraisal of one’ work.
leisure A discretionary activity that includes simple relaxation, activities for enjoyment, and creative pursuits.
meaning-mission fit Alignment between people’s personal intentions and their company’s mission.
mentor or developmental coach A person who is part teacher, sponsor, model, and counselor who facilitates
on-the-job learning to help a new hire do the work required in his or her present role and to prepare for future roles.
passion A strong inclination toward an activity that individuals like (or even love), that they value (and thus find important), and in which they invest time and energy.
reality shock Situation in which what you learn in the classroom does not always transfer directly into the “real world” and does not represent all you need to know.
social cognitive career theory (SCCT) Proposes career choice is a result of the application of Bandura’s social cognitive theory, especially the concept of self-efficacy.
work–family conflict The feeling of being pulled in multiple directions by incompatible demands from job and family.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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Dying and Bereavement
13.1 DEFINITIONS AND ETHICAL ISSUES Sociocultural Definitions of Death • Legal and Medical Definitions • Ethical Issues • Current Controversies: The Terri Schiavo Case • The Price of Life-Sustaining Care
13.2 THINKING ABOUT DEATH: PERSONAL ASPECTS Discovering Development: A Self-Reflective Exercise on Death • Life-Course Approach to Dying • Dealing With One’s Own Death • Death Anxiety
13.3 END-OF-LIFE ISSUES Creating a Final Scenario • The Hospice Option • Making Your End-of-Life Intentions Known
13.4 SURVIVING THE LOSS: THE GRIEVING PROCESS The Grief Process • Normal Grief Reactions • Coping With Grief • How Do We Know?: Grief Processing and Avoidance in the United States and China • Complicated or Prolonged Grief Disorder • Adult Developmental Aspects of Grief • Conclusion
SOCIAL POLICY IMPLICATIONS Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 13
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376 CHAPTER 13
WHEN FAMOUS PEOPLE SUCH AS HEATH LEDGER, MICHAEL JACKSON, WHITNEY HOUSTON, OR AMY WINEHOUSE DIE UNEXPECTEDLY , people are confronted with the reality that death happens to everyone.
We have a paradoxical relationship with death. Sometimes we are fascinated by it. As tourists, we visit places where famous people died or are buried. We watch as television newscasts show scenes of devastation in natural disasters and war. But when it comes to pondering our own death or people close to us, we have many problems. As French writer and reformer La Rochefoucauld wrote over 300 years ago, “looking into the sun is easier than contemplating our death.” When death is personal, we become uneasy. Looking at the sun is hard indeed.
In this chapter we delve into thanatology. Thanatology is the study of death, dying, grief,
bereavement, and social attitudes toward these issues. We first consider definitional and ethical issues surrounding death. Next, we look specifi- cally at the process of dying. Dealing with grief is important for survivors, so we consider this topic in the third section. Finally, we examine how people view death at different points in the life span.
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13.1 Definitions and Ethical Issues LEARNING OBJECTIVES
How is death defined? What legal and medical criteria are used to
determine when death occurs? What are the ethical dilemmas surrounding
euthanasia? What issues surround the costs of life-sustaining
care?
Ernesto and Paulina had been married 48 years when Ernesto developed terminal pancreatic cancer. Ernesto was suffering terrible pain and begged Paulina to make it stop. He said she would not let their pet suffer this way, so why let him? Paulina heard about “mercy killing” that involved administering high dosages of certain medica- tions, but she believed this was the same as murder. Yet, she could hardly bear to watch her beloved husband suf- fer. Paulina wondered what she should do.
When one first thinks about it, death seems a simple concept to define: It is the point when a per- son is no longer alive. Similarly, dying is simply the process of making the transition from being alive to being dead. It all seems clear enough, doesn’t it? But death and dying are actually far more complicated concepts.
As we will see, there are many cultural and reli- gious differences in the definition of death and the cus- toms surrounding it. The meaning of death depends on the observer’s perspective as well as the specific medical and biological criteria one uses.
Sociocultural Definitions of Death What comes to mind when you hear the word death ? A driver killed in a traffic accident? A transition to an eternal reward? Flags at half-staff ? A cemetery? A
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DYING AND BEREAVEMENT 377
car battery that doesn’t work anymore? Each of these possibilities represents a way death can be considered in Western culture and has its own set of specific rit- uals (Bustos, 2007; Penson, 2004). All cultures have their own views. Some cultures pull their hair (Lewis, 2013). Melanesians have a term, mate , that includes the extremely sick, the very old, and the dead; the term toa refers to all other living people (Counts & Counts, 1985). Other South Pacific cultures believe the life force leaves the body during sleep or illness; sleep, illness, and death are considered together. Thus people “die” many times before experiencing “final death.”
In Ghana people are said to have a “peaceful” or “good” death if the dying person finished all busi- ness and made peace with others before death, and implies being at peace with his or her own death (van der Geest, 2004). A good and peaceful death comes “naturally” after a long and well-spent life. Such a death preferably takes place at home, the epitome of peacefulness, surrounded by children and grand- children. Finally, a good death is a death accepted by the relatives.
Mourning rituals and states of bereavement also vary in different cultures (Lee, 2010; Norton & Gino, in press). There is great variability across cultures in the meaning of death and whether there are rituals or other behaviors to express grief. Some cultures have formalized periods of time during which cer- tain prayers or rituals are performed. After the death of a close relative, Orthodox Jews recite ritual prayers and cover all the mirrors in the house. The men slash their ties as a symbol of loss. In Papua New Guinea, there are accepted time periods for phases of grief (Herner, 2010). The Muscogee Creek tribe’s rituals include digging the grave by hand and giving a “fare- well handshake” by throwing a handful of dirt into the grave before covering it (Walker & Balk, 2007). Ancestor worship, a deep respectful feeling toward individuals from whom a family is descended or who are important to them, is an important part of customs of death in many Asian cultures (Roszko, 2010). We must keep in mind the experiences of our culture or particular group may not generalize to other cultures or groups.
Death can be a truly cross-cultural experience. The international outpouring of grief over the death of
world leaders such Nelson Mandela in 2013, the thou- sands killed in the terrorist attacks against the United States in September 2001, and the hundreds of thou- sands killed in such natural disasters as the earthquake in Haiti in 2010 drew much attention to the ways the deaths of people we do not know personally can still affect us. It is at these times we realize death happens to us all and death can simultaneously be personal and public.
The many ways of viewing death can be seen in various customs involving funerals. You may have experienced a range of different types of funeral cus- toms, from small, private services to elaborate ritu- als. Variations in the customs surrounding death are reflected in some of the most iconic structures on earth, such as the pyramids in Egypt, and some of the most beautiful, such as the Taj Mahal in India.
Legal and Medical Definitions Sociocultural approaches help us understand the dif- ferent ways people conceptualize and understand death; but they do not address a fundamental question: How do we determine someone has died? The medical and legal communities grappled with this question for centuries and continue to do so today. Let’s see what the current answers are.
Determining when death occurs has always been subjective. For hundreds of years, people accepted and applied the criteria that now define clinical death : lack of heartbeat and respiration. Today, however, the most widely accepted criteria are those that characterize
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378 CHAPTER 13
whole-brain death . In 1981, the President’s Commis- sion for the Ethical Study of Problems in Medicine and Biomedical and Behavioral Research established sev- eral criteria still used today that must be met for the determination of whole-brain death:
No spontaneous movement in response to any stimuli
No spontaneous respirations for at least one hour Total lack of responsiveness to even the most pain-
ful stimuli No eye movements, blinking, or pupil responses No postural activity, swallowing, yawning, or
vocalizing No motor reflexes A flat electroencephalogram (EEG) for at least
10 minutes No change in any of these criteria when they are
tested again 24 hours later
For a person to be declared dead, all eight cri- teria must be met. Moreover, other conditions that mimic death—such as deep coma, hypothermia, or drug overdose—must be ruled out. Finally, accord- ing to most hospitals, the lack of brain activity must occur both in the brainstem that involves vegetative functions such as heartbeat and respiration, and in the cortex, involving higher processes such as think- ing. In the United States, all 50 states and the Dis- trict of Columbia use the whole-brain standard to define death.
A major problem facing the medical profession is how brain death is diagnosed in practice (Sung & Greer, 2011). In part this is due to variable intervals taken to make the second assessment (Lustbader et al., 2011). Because patients declared brain dead on first examination do not spontaneously recover brain stem function, and because long delays in second assess- ments lower the rate that patients’ families agree to organ donation, some medical professionals are calling for a single assessment or at least a simpler, more direct process (Sung & Greer, 2011).
Brain death is also controversial from some reli- gious perspectives. For example, some Islamic schol- ars argue brain death is not complete death; complete death must include the cessation of respiration (Bedir
& Aksoy, 2011). Roman Catholics focus on what they term “natural death” (Verheijde, 2010).
It is possible for a person’s cortical functioning to cease while brainstem activity continues; this is a persistent vegetative state , from which the person does not recover . This condition can occur following dis- ruption of the blood flow to the brain, a severe head injury, or a drug overdose. Persistent vegetative state allows for spontaneous heartbeat and respiration but not for consciousness. The whole-brain standard does not permit a declaration of death for someone who is in a persistent vegetative state. Because of conditions like persistent vegetative state, family members some- times face difficult ethical decisions concerning care for the individual. These issues are the focus of the next section.
Ethical Issues An ambulance screeches to a halt and emergency personnel rush a woman into the emergency room. As a result of an accident at a swimming pool, she has no pulse and no respiration. Working rapidly, the trauma team reestablishes a heartbeat through electric shock. A respirator is connected. An EEG and other tests reveal extensive and irreversible brain damage—she is in a persistent vegetative state. What should be done?
This is an example of the kinds of problems faced in the field of bioethics , the study of the interface between human values and technological advances in health and life sciences . Bioethics grew from two bases: respect for individual freedom and the impossibility of establish- ing any single version of morality by rational argument or common sense. Both of these factors are increas- ingly based on empirical evidence and cultural contexts (Priaulx, 2013; Sherwin, 2011). In practice, bioethics emphasizes the importance of individual choice and the minimization of harm over the maximization of good. That is, bioethics requires people to weigh how much the patient will benefit from a treatment relative to the amount of suffering he or she will endure as a result of the treatment. Examples of the tough choices required are those facing cancer patients about aggres- sive treatment for cancer that is quite likely to be fatal in any case and those facing family members about whether to turn off a life-support machine attached to their loved one.
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DYING AND BEREAVEMENT 379
In the arena of death and dying, the most important bioethical issue is euthanasia —the practice of ending life for reasons of mercy . The moral dilemma posed by euthanasia becomes apparent when trying to decide the circumstances a person’s life should be ended, that implicitly forces one to place a value on the life of another (Bedir & Aksoy, 2011; Munoz & Fox, 2013; Verheijde, 2010). It also makes us think about the difference between “killing” and “letting die” at the end of life (Dickens, Boyle, & Ganzini, 2008). In our society, this dilemma occurs most often when a person is being kept alive by machines or when someone is suffering from a terminal illness. This is the situation confronting Ernesto and Paulina in the opening vignette.
Euthanasia. Euthanasia can be carried out in two dif- ferent ways: actively and passively (Moeller, Lewis, & Werth, 2010). Active euthanasia involves the deliberate ending of someone’s life, that may be based on a clear statement of the person’s wishes or be a decision made by someone else who has the legal authority to do so . Usu- ally, this involves situations when people are in a per- sistent vegetative state or suffer from the end stages of a terminal disease. Examples of active euthanasia would be administering a drug overdose or ending a person’s life through so-called mercy killing.
A second form of euthanasia , passive euthanasia , involves allowing a person to die by withholding avail- able treatment . A ventilator might be disconnected, chemotherapy might be withheld from a patient with terminal cancer, a surgical procedure might not be performed, or food could be withdrawn.
Some ethicists and medical professionals do not differentiate active and passive euthanasia. The Euro- pean Association of Palliative Care (EAPC, 2011) established an ethics task force opposing euthanasia, and claims the expression “passive euthanasia” is a contradiction in terms because any ending of a life is by definition active. Despite these concerns, Garrard and Wilkinson (2005) conclude there is really no rea- son to abandon the category provided it is properly and narrowly understood and “euthanasia reasons” for withdrawing or withholding life-prolonging treat- ment are carefully distinguished from other reasons, such as family members not wanting to wait to divide the patient’s estate. Still, whether there is a difference
between active and passive euthanasia remains contro- versial (Busch & Rodogno, 2011).
Most Americans favor such actions as discon- necting life support in situations involving patients in a persistent vegetative state, withholding treatment if the person agrees or is in the later stages of a termi- nal illness, and the concept of assisted death. But feel- ings also run strongly against such actions for religious or other reasons (Bedir & Aksoy, 2011; Meilaender, 2013; Verheijde, 2010). Even political debates incor- porate the issue, as demonstrated in the summer of 2009 in the United States when opponents of President Obama’s health care reform falsely claimed “death pan- els” would make decisions about terminating life sup- port if the reform measure passed.
Globally, opinions about euthanasia vary (Bosshard & Materstvedt, 2011). A systematic survey of layper- sons and health care professionals in the Netherlands and Belgium found most said they would support euthanasia under specific conditions (Teisseyre, Mul- let, & Sorum, 2005). Respondents assigned most importance to patients’ specific requests for eutha- nasia and supported these requests, but they did not view patients’ willingness to donate organs—without another compelling reason—as an acceptable reason to request euthanasia.
Greek physicians and nurses oppose euthana- sia, but support the legalization of hastening the death of an advanced cancer patient (e.g., not reviv- ing a terminal cancer patient) (Parpa, Mystaki- dou, Tsilika, Sakkas, Patiraki, Pistevou-Gombaki et al., 2010). Other analyses show opinions are often related to religious or political beliefs (Swinton & Payne, 2009). Western Europeans tend to view active euthanasia more positively based on less influence of religion and more social welfare services than res- idents of Eastern European and Islamic countries, who are more influenced by religious beliefs arguing against such practices (Baumann et al., 2011; Góra & Mach, 2010; Hains & Hulbert-Williams, in press; Nayernouri, 2011).
Disconnecting a life support system is one thing; withholding nourishment from a terminally ill per- son is quite another for many people. Indeed, such cases often end up in court. The first high-profile legal case involving passive euthanasia in the United States was brought to the courts in 1990; the U.S. Supreme
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Court took up the case of Nancy Cruzan, whose fam- ily wanted to end her forced feeding. The court ruled, unless clear and incontrovertible evidence is pre- sented that an individual desires to have nourishment stopped, such as through a health care power of attor- ney or living will, a third party (such as a parent or partner), cannot decide to end it.
The most widely publicized and politicized case of euthanasia in the United States involved Terri Schiavo, who died in Florida in 2005. This extremely controversial case involving the withdrawal of forced
feeding had its origins in a disagreement between Terri’s husband Michael, who said Terri would have wanted to die with dignity and therefore the feeding tube should be removed, and her parents who argued the opposite. The debate resulted in the involvement of government officials, state and federal legislators, and the courts. As discussed in the Current Contro- versies feature, such cases reveal the difficult legal, medical, and ethical issues as well as the high degree of emotion surrounding the topic of euthanasia and death with dignity.
CURRENT CONTROVERSIES: THE TERRI SCHIAVO CASE On February 25, 1990, 26 -year-old Terri Schiavo collapsed in her home from a possible potassium imbalance caused by an eating disorder, temporarily stopping her heart and cutting off oxygen to her brain. On March 31, 2005, Terri Schiavo died after her feeding tube was removed 13 days earlier. On these two points everyone connected with Terri’s case agreed. But on all other essential aspects of it, Terri’s husband Michael and Terri’s parents deeply disagreed.
The central point of disagreement was Terri’s medi- cal condition. Terri’s husband and numerous physicians argued she was in a persistent vegetative state. Based on this diagnosis, Michael Schiavo requested Terri’s feeding tube be withdrawn and she be allowed to die with dignity in the way he asserted she would have wanted to.
Terri’s parents and other physicians said she was not in a persistent vegetative state and was capable of recognizing them and others. Based on this diagno- sis, their belief Terri would not want the intervention
stopped, and their contention passive euthanasia is morally wrong, they fought Michael’s attempts to remove the feeding tube.
What made this case especially difficult was that Terri left no written instructions clearly stating her thoughts and intentions on the issue. The ensuing legal and political debates became based on what various people thought Terri would have wanted and reflected various aspects of people’s positions on personal rights regarding life and death.
The legal and political battles began in 1993 when Terri’s parents tried unsuccessfully to have Michael removed as Terri’s guardian. But the most heated aspects of the case began in 2000 when a circuit court judge ruled Terri’s feeding tube could be removed based on his belief she had told Michael she would not have wanted it. In April 2001, the feeding tube was removed after state courts and the U.S. Supreme Court refused to hear the case. However, the tube was reinserted 2 days later upon another judge’s order. In November 2002, the original circuit court judge ruled Terri had no hope of recovery and again ordered the tube removed, an order eventually carried out in October 2003. Within a week, however, Florida Governor Jeb Bush signed a bill passed by the Florida legislature requiring the tube be reinserted. This law was ruled unconstitutional by the Florida Supreme Court in September 2004. In February 2005, the original circuit court judge again ordered the tube removed. Between March 16 and March 27, the Florida House introduced and passed a bill that require the tube be reinserted, but the Florida Senate defeated a somewhat different version of the bill. From March 19 to 21, bills that would allow a federal court to review the case passed in the U.S. House of Representatives and the U.S. Senate, but the two versions could not be reconciled. Over the next ten days, the Florida Supreme Court, the U.S. district court, and a U.S. circuit court refused to hear the case, as did the U.S. Supreme Court. Ge
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DYING AND BEREAVEMENT 381
Physician-Assisted Suicide. Taking one’s own life through suicide has never been popular in the United States because of religious and other prohibitions. In other cultures, such as Japan, suicide is viewed as an honorable way to die under certain circumstances (Joiner, 2010).
Attitudes regarding suicide in certain situations are changing. Much of this change concerns the topic of physician-assisted suicide , in which physicians pro- vide dying patients with a fatal dose of medication that the patient self-administers. A Harris Poll released in 2011 indicated 70 % of all adult respondents (and 62 % of those over age 65 ) agreed people who are termi- nally ill, in great pain and have no chance of recov- ery should have the right to choose to end their lives. Only 17 % of the respondents disagreed. By a margin of 58 % to 20 %, respondents supported physician- assisted suicide for such patients (Harris Interac- tive, 2011). A similar poll in 2012 by NPR-Truven Health Analytics showed 55 % of Americans favored physician assisted suicide for those with less than six months to live (Hensley, 2012). Clearly, most Ameri- cans favor having a choice.
Several countries—including Switzerland, Belgium, and Colombia—tolerate physician-assisted suicide. In 1984, the Dutch Supreme Court eliminated prosecution of physicians who assist in suicide if five criteria are met:
1. The patient’s condition is intolerable with no hope for improvement.
2. No relief is available. 3. The patient is competent. 4. The patient makes a request repeatedly over time. 5. Two physicians review the case and agree with the
patient’s request.
The Dutch Parliament approved the policy in April 2001, making the Netherlands the first country to have an official policy legalizing physician-assisted suicide (Deutsch, 2001).
Voters in Oregon passed the Death With Dig- nity Act in 1994, the first physician-assisted sui- cide law in the United States (Initiative- 1000 , the Death With Dignity Act passed in Washington state in 2008, was modeled after the Oregon law). These laws make it legal for people to request a lethal dose of medication if they have a terminal disease and make the request voluntarily. Although the U.S. Supreme Court ruled in two cases in 1997 ( Vacco v. Quill and Washington v. Glucksberg ) there is no right to assisted suicide, the Court decided in 1998 not to overturn the Oregon law.
The Oregon and Washington laws are more restrictive than the law in the Netherlands (Deutsch, 2001). Both laws provide for people to obtain and use prescriptions for self-administered lethal doses of medication. The law requires a physician to inform the person he or she is terminally ill and describe alternative options (e.g., hospice care, pain con- trol). The person must be mentally competent and make two oral and one written request, with at least 15 days between each oral request. Such provisions are included to ensure people making the request fully understand the issues and the request is not made hastily.
Several studies examined the impact of the Ore- gon law. The numbers of patients who received pre- scriptions and died between 1998 and 2012 are shown in Figure 13.1 . Over the period, a total of 525 patients died under the terms of the law (Oregon Department of Human Services, 2013). Comprehensive reviews
The original circuit court judge rejected a final attempt by Terri’s parents to have the feeding tube reinserted.
The public debate on the case was as long and complex as the legal and political arguments. The debate had several positive outcomes. The legal and political complexities dramatically illustrated the need for people to reflect on end-of-life issues and make their wishes known to family members and others (e.g., health care providers) in writing. The case also brought to light the high cost of long-term care, the difficul- ties in actually determining whether someone is in a
persistent vegetative state (and what that implies about life), the tough moral and ethical issues surrounding the withdrawal of nutrition, and the individual’s personal feelings about death. The legal and medical commu- nities have proposed reforms concerning how these types of cases are heard in the courts and the processes used to resolve them (Berlinger, Jennings, & Wolf, 2013; Moran, 2008).
What do you think? Should Terri Schiavo’s feed- ing tube have been removed? Discuss your thoughts in class.
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of the implementation of the Oregon law soon after its passage concluded all safeguards worked and such things as depression, coercion, and misunder- standing of the law were carefully screened (Orentli- cher, 2000). Available data also indicate laws such as Oregon’s has psychological benefits for patients, who value having autonomy in death as in life, especially in situations involving unbearable suffering ( Hendry, Pasterfield, Lewis, Carter, Hodgson, & Wilkinson, 2013).
There is no question the debate over physician- assisted suicide will continue. As the technology to keep people alive continues to improve, the ethical issues about active euthanasia in general and phy- sician-assisted suicide in particular will continue to become more complex and will likely focus increas- ingly on quality of life.
The Price of Life-Sustaining Care A growing debate in the United States, particularly in the aftermath of the Affordable Care Act passed in 2010, concerns the financial, personal, and moral costs of keeping people alive on life-support machines and continuing aggressive care when people have terminal conditions. Debate continues on whether secondary
health conditions in terminally ill people should be treated. The argument is such care is expensive, these people will die soon anyway, and needlessly prolong- ing life is a burden on society.
However, many others argue all means possible should be used, whether for a premature infant or an older adult, to keep them alive despite the high cost and possible risk of negative side effects of the treat- ment or intervention. They argue life is precious, and humans should not “play God” and decide when it should end.
There is no question extraordinary interventions are expensive. Health care costs can soar during the last year of a person’s life. Data indicate less than 7 % of people who receive hospital care die each year, but account for nearly 25 % of all Medicare expenditures (Adamy & McGinty, 2012). Expenditures are typically less for those having advance directives (discussed later in this chapter).
The biggest challenge in confronting these differ- ences in approach and cost is the difficulty in decid- ing when to treat or not treat a disease a person has. There are no easy answers. Witness the loud criticism when research evidence indicated various types of cancer screening (e.g., breast, prostate) should not be
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Figure 13.1 Number of Oregon Death with Dignity Act prescription (Rx) recipients and deaths. Source: http://public.health.oregon. ggov/ProviderPartnerResources/Evalu- ationResearch/DeathwithDignityAct/ ages/a de spPages/arindex.Aspx
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DYING AND BEREAVEMENT 383
provided to everyone as early or as often as initially thought. Despite the lack of evidence to support and the cost of continuing traditional approaches, many patients and physicians do so anyway. Failure to base care on evidence has a price. Whether that is affordable in the long run seems unlikely.
Adult Development in Action How should the biopsychosocial model influence political debates about dying and death?
13.2 Thinking About Death: Personal Aspects LEARNING OBJECTIVES
How do feelings about death change over adulthood?
How do people deal with their own death? What is death anxiety, and how do people
show it?
Jean is a 49 -year-old woman whose parents have both died in the past three years. She now realizes she is the oldest living member of her family (she has two younger siblings). She started thinking about the fact that some- day she too will die. Jean gets anxious when she thinks about her death, and tries to block it out of her mind.
Like Jean, most people are uncomfortable think- ing about their own death, especially if they think it will be unpleasant. As one research participant put it, “You are nuts if you aren’t afraid of death” (Kalish & Reynolds, 1976). Still, death is a paradox, as we noted at the beginning of the chapter. That is, we are afraid of or anxious about death but we are drawn to it, some- times in public ways. We examine this paradox at the personal level in this section. Specifically, we focus on two questions: How do people’s feelings about death differ with age? What is it about death we fear or that makes us anxious?
Before proceeding, however, take a few minutes to complete the exercise in the Discovering Development feature.
DISCOVERING DEVELOPMENT: A SELF-REFLECTIVE EXERCISE ON DEATH As we noted, thinking about death, especially one’s own, is difficult. One common way to remember people is through an obituary, an experience we may have with hundreds of people we know but never our own. Here’s a chance to think about one’s own death from that perspective.
In 200 words or less, write your own obituary. Be sure to include your age and cause of death. List your lifetime accomplishments. Don’t for- get to list your survivors.
Think about all the things you will have done that are not listed in your obituary. List some of them.
Think of all the friends you will have made and how you will have affected them.
Would you make any changes in your obituary now?
A Life-Course Approach to Dying Suppose you learned today you had only a few months to live. How would you feel about dying? Do you think people of different ages feel the same way? It probably doesn’t surprise you to learn feelings about dying vary across adulthood such as adults of various ages who live with a person with a life-threatening illness. Each comes to terms with death in an individual and a family- based way, and together they co-create ways the patient meets his or her goals (Bergdahl, Benzein, Ternestedt, Elmberger, & Andershed, in press; Carlander, Ternest- edt, Sahlberg-Blom, Hellström, & Sandberg, 2011).
Although not specifically addressed in research, the shift from formal operational thinking to post- formal thinking (see Chapter 7 ) could be important in young adults’ contemplation of death. Presumably, this shift in cognitive development is accompanied by a lessening of the feeling of immortality in adolescence to one that integrates personal feelings and emotions with their thinking.
Midlife is the time when most people in developed countries confront the death of their parents. Until that point, people tend not to think much about their own death; the fact their parents are still alive buffers them
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from reality. After all, in the normal course of events, our parents are supposed to die before we do.
Once their parents die, people realize they are now the oldest generation of their family—the next in line to die. Reading the obituary pages, they are reminded of this, as the ages of many of the people who died get closer and closer to their own.
Probably as a result of this growing realization of their own mortality, middle-aged adults’ sense of time undergoes a subtle yet profound change. It changes from an emphasis on how long they have already lived to how long they have left to live, a shift that increases into late life (Cicirelli, 2006; Maxfield, Solomon, Pyszc- zynski, & Greenberg, 2010). This may lead to occupa- tional change or other redirection such as improving relationships that deteriorated over the years.
In general, older adults are less anxious about death and more accepting of it than any other age group. Still, because the discrepancy between desired and expected number of years left to live is greater for young-old than for mid-old adults, anxiety is higher for young- old adults (Cicirelli, 2006). In part, the greater over- all acceptance of death results from the achievement of ego integrity, as described in Chapter 9 . For other older adults, the joy of living is diminishing. More than any other group, they experienced loss of family and friends and have come to terms with their own mor- tality. Older adults have more chronic diseases (see Chapters 3 and 4 ) that are not likely to go away. They may feel their most important life tasks have been completed (Kastenbaum, 1999).
Understanding how adults deal with death and their consequent feelings of grief is best approached from the perspective of attachment theory (Mercer, 2011; Stroebe, Schut, & Stroebe, 2005). In this view, a person’s reactions are a natural consequence of form- ing attachments and then losing them. We consider adult grief a bit later in the chapter.
Dealing With One’s Own Death Many authors have tried to describe the dying process, often using the metaphor of a trajectory that captures the duration of time between the onset of dying (e.g., from the diagnosis of a fatal disease) as well as death and the course of the dying process (Field & Cassel, 2010; Kheirbek, Alemi, Citron, Afaq, Wu, & Fletcher, 2013). These dying trajectories vary a great deal across diseases, as illustrated in Figure 13.2 . Some diseases, such as lung cancer, have a clear and rapid period of decline; this “terminal phase” is often used to deter- mine eligibility for certain services (e.g., hospice, discussed later). Other diseases, such as congestive heart failure, have no clear terminal phase. The two approaches of describing the dying process we con- sider will try to account for both types of trajectories.
Kübler-Ross’s Work. Elisabeth Kübler-Ross changed the way we approach dying. When she began her inves- tigations into the dying process in the 1960s, such research was controversial; her physician colleagues initially were outraged and some even denied their patients were terminally ill. Still, she persisted. More than
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Best Figure 13.2 Some fatal diseases, such as lung cancer, have a clear decline phase, whereas others, such as congestive heart failure, do not. Source: From Skolnick, A. A. (1998). MediCaring project to demonstrate and evaluate innovative end-of-life program for chronically ill. Journal of the American Medical Association, 279, 1511–1512. Reprinted with permission of the American Medical Association.
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DYING AND BEREAVEMENT 385
200 interviews with terminally ill people convinced her most people experienced several emotional reactions. Using her experiences, she described five reactions that represented the ways people dealt with death: denial, anger, bargaining, depression, and acceptance (Kübler- Ross, 1969). Although they were first presented as a sequence, it was subsequently realized the emotions can overlap and be experienced in different order.
Although she believed these five stages represent the typical range of emotional development in the dying, Kübler-Ross (1974) cautioned not everyone experiences all of them or progresses through them at the same rate or in the same order. Research sup- ports the view her “stages” should not be viewed as a sequence (Charlton & Verghese, 2010; Parkes, 2013). In fact, we could actually harm dying people by con- sidering these stages as fixed and universal. Individ- ual differences are great. Emotional responses may vary in intensity throughout the dying process. Thus, the goal in applying Kübler-Ross’s ideas to real-world settings would be to help people achieve an appro- priate death: one that meets the needs of the dying person, allowing him or her to work out each problem as it comes.
A Contextual Theory of Dying. Describing the pro- cess of dying is difficult. One reason for these prob- lems is the realization there is no one right way to die, although there may be better or worse ways of coping (Corr, 2010a,b; Corr & Corr, 2013; Corr, Corr, & Nabe, 2008). Corr identified four dimensions of the issues or tasks a dying person faces from their perspective: bodily needs, psychological security, interpersonal attachments, and spiritual energy and hope. This holistic approach acknowledges individual differences and rejects broad generalizations. Corr’s task work approach also recognizes the importance of the coping efforts of family members, friends, and caregivers as well as those of the dying person.
Kastenbaum and Thuell (1995) argue what is needed is an even broader contextual approach that takes a more inclusive view of the dying process. They point out theories must be able to handle people who have a wide variety of terminal illnesses and be sen- sitive to dying people’s own perspectives and values related to death. The socio-environmental context where dying occurs often changes over time and must
be recognized. A person may begin the dying process living independently but end up in a long-term care facility. Such moves may have profound implications for how the person copes with dying. A contextual approach provides guidance for health care profession- als and families for discussing how to protect the qual- ity of life, provide better care, and prepare caregivers for dealing with the end of life. Such an approach would also provide research questions such as how does one’s acceptance of dying change across various stages?
Although we do not yet have a comprehensive theory of dying, we examine people’s experiences as a narrative that can be written from many points of view (e.g., the patient, family members, caregivers). What emerges would be a rich description of a dynamically changing process.
Death Anxiety We have seen how people view death varies with age. In the process, we encountered the notion of feeling anxious about death. Death anxiety refers to people’s anxiety or even fear of death and dying. Death anxiety is tough to pin down; indeed, it is the ethereal nature of death rather than something about it in particular, that makes us feel so uncomfortable. We cannot put our finger on something specific about death causes us to feel uneasy. Because of this, we must look for indirect behavioral evidence to document death anxiety. Research findings suggest death anxiety is a complex, multidimensional construct.
For nearly three decades, researchers have applied terror management theory as a framework to study death anxiety (Burke, Martens, & Faucher, 2010; Tam, 2013). Terror management theory addresses the issue of why people engage in certain behaviors to achieve par- ticular psychological states based on their deeply rooted concerns about mortality (Arndt & Vess, 2008). The theory proposes ensuring the continuation of one’s life is the primary motive underlying behavior and all other motives can be traced to this basic one.
Additionally, some suggest older adults present an existential threat for the younger and middle-aged adults because they remind us all that death is ines- capable, the body is fallible, and the bases that we may secure self-esteem (and manage death anxiety) are tran- sitory (Martens, Goldenberg, & Greenberg, 2005). That may be why some people seek cosmetic surgery as a way to deal with their death anxiety (Tam, 2013). Thus,
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386 CHAPTER 13
death anxiety is a reflection of one’s concern over dying, an outcome that would violate the prime motive.
Neuroimaging research shows terror management theory provides a useful framework for studying brain activity related to death anxiety. Quirin, Loktyushin, Arndt, Küstermann, Lo, Kuhl, and colleagues (2012) found brain activity in the right amygdala, left rostral anterior cingulate cortex, and right caudate nucleus was greater when male participants were answering questions about fear of death and dying than when they were answering questions about dental pain. Similarly, electrical activity in the brain indicates people defend themselves against emotions related to death (Klackl, Jonas, & Kronbichler, 2013). There is neurophysi- ological evidence that shows Jean’s attempts to block thoughts of her own death in the opening vignette are common across people.
On the basis of several diverse studies using many different measures, researchers now conclude death anxiety consists of several components. Each of these components is most easily described with terms that resemble examples of great concern (anxi- ety) but cannot be tied to any one specific focus. Some research on U.S. and Atlantic Canadian adults indicates components of death anxiety included pain, body malfunction, humiliation, rejection, nonbeing, punishment, interruption of goals, being destroyed, and negative impact on survivors (Power & Smith, 2008). To complicate matters further, each of these components can be assessed at any of three levels: public, private, and nonconscious. What we admit feeling about death in public may differ greatly from what we feel when we are alone with our own thoughts. In short, the measurement of death anxi- ety is complex and researchers need to specify what aspects they are assessing.
Much research has been conducted to learn what demographic and personality variables are related to death anxiety. Although the results often are ambigu- ous, some patterns have emerged. Older adults tend to have lower death anxiety than younger adults, perhaps because of their tendency to engage in life review, have a different perspective about time, and their higher level of religious motivation (Henrie, 2010). Men show greater fear of the unknown than women, but women report more specific fear of the dying process (Cicirelli, 2001). In Taiwan, higher death anxiety among patients
with cancer is associated with not having a purpose in life and level of fear of disease relapse (Tang, Chiou, Lin, Wang, & Liand, 2011).
Strange as it may seem, death anxiety may have a beneficial side. For one thing, being afraid to die means we often go to great lengths to make sure we stay alive, as argued by terror management theory (Burke, Mar- tens, & Faucher, 2010). Because staying alive ensures the continuation and socialization of the species, fear of death serves as a motivation to have children and raise them properly.
Learning to Deal With Death Anxiety. Although some degree of death anxiety may be appropriate, we must guard against letting it become powerful enough to interfere with normal daily routines. Sev- eral ways exist to help us in this endeavor. Perhaps the one most often used is to live life to the fullest. Kalish (1984, 1987) argues people who do this enjoy what they have; although they may still fear death and feel cheated, they have few regrets. Adolescents are par- ticularly likely to do this; research shows teenagers, especially males, engage in risky behavior that is cor- related with low death anxiety (Ben-Zur & Zeidner, 2009; Cotter, 2003).
Koestenbaum (1976) proposes several exercises and questions to increase one’s death awareness. Some of these are to write your own obituary (like you did earlier in this chapter) and to plan your own death and funeral services. You can also ask yourself: “What circumstances would help make my death acceptable?” “Is death the sort of thing that could happen to me right now?”
These questions serve as a basis for an increas- ingly popular way to reduce anxiety: death educa- tion. Most death education programs combine factual information about death with issues aimed at reduc- ing anxiety and fear to increase sensitivity to others’ feelings. These programs vary widely in orientation; they include such topics as philosophy, ethics, psychol- ogy, drama, religion, medicine, art, and many others. Additionally, they focus on death, the process of dying, grief and bereavement, or any combination of those. In general, death education programs help primarily by increasing our awareness of the complex emotions felt and expressed by dying people and their families. It is important to make education programs reflect the diverse backgrounds of the participants (Fowler, 2008).
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DYING AND BEREAVEMENT 387
Research shows participating in experiential work- shops about death significantly lowers death anxiety in younger, middle-aged, and older adults and raises awareness about the importance of advance directives (Moeller, Lewis, & Werth, 2010).
Jean is a 72 -year-old woman recently diagnosed with advanced colon cancer. She has vivid memories of her father dying a long, protracted death in great pain. Jean is afraid she will suffer the same fate. She heard the hos- pice in town emphasizes pain management and provides a lot of support for families. Jean wonders whether that is something she should explore in the time has left.
When people think about how they would like to die, no one chooses a slow, painful process where medical intervention continues well beyond the point of increasing quality of life over quantity of life. How- ever, medical intervention such as life support or car- diopulmonary resuscitation (CPR), are common even in situations that people would prefer them not to be used. How can people make their wishes about how they want to experience the end of their life known?
Creating a Final Scenario When given the chance, many adults would like to dis- cuss a variety of issues, collectively called end-of-life issues : management of the final phase of life, after- death disposition of their body, memorial services, and distribution of assets (Moeller et al., 2010). How these issues are confronted represents a significant genera- tional shift (Green, 2008). Parents and grandparents of the baby boom generation spoke respectfully about those who had “passed away,” and very rarely planned ahead for or made their wishes known about medical care they did or did not want. Baby boomers are far more likely to plan and be more matter-of-fact. People want to manage the final part of their lives by think- ing through the choices between traditional care (e.g., provided by hospitals and nursing homes) and alterna- tives (such as hospices, that we discuss in the next sec- tion), completing advance directives (e.g., health care power of attorney, living will), resolving key personal relationships, and perhaps choosing the alternative of ending one’s life prematurely through euthanasia.
What happens to one’s body and how one is memorialized is important to most people. Is a tradi- tional burial preferred over cremation? A traditional funeral over a memorial service? Such choices often are based in people’s religious beliefs and their desire for privacy for their families after they have died.
Making sure one’s estate and personal effects are passed on appropriately often is overlooked. Making a will is especially important to ensure one’s wishes are
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Adult Development In Action How might different approaches to lowering death anxiety be useful to you as a health care worker?
13.3 End-of-Life Issues LEARNING OBJECTIVES
What are end-of-life issues? What is a final scenario?
What is hospice? How does hospice relate to end-of-life issues?
How does one make end-of-life desires and decisions known?
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388 CHAPTER 13
carried out. Providing for the informal distribution of personal effects also helps prevent disputes between family members.
Whether people choose to address these issues formally or informally, it is important they be given the opportunity to do so. In many cases, family members are reluctant to discuss these matters with the dying relative because of their own anxiety about death. Making such choices known about how they do and do not want their lives to end constitutes a final scenario .
One of the most difficult and important parts of a final scenario for most people is the process of separa- tion from family and friends (Corr et al., 2008; Corr & Corr, 2013; Wanzer & Glenmullen, 2007). The final days, weeks, and months of life provide opportunities to affirm love, resolve conflicts, and provide peace to dying people. The failure to complete this process often leaves survivors feeling they did not achieve closure in the relationship, and can result in bitterness toward the deceased.
Health care workers realize the importance of giv- ing dying patients the chance to create a final scenario and recognize the uniqueness of each person’s final passage. A key part of their role is to ease this pro- cess (Wanzer & Glenmullen, 2007). Any given final scenario reflects the individual’s personal past, that is the unique combination of the development forces the person experienced. Primary attention is paid to how people’s total life experiences prepared them to face end-of-life issues (Moeller et al., 2010).
One’s final scenario helps family and friends inter- pret one’s death, especially when the scenario is con- structed jointly, such as between spouses, and when communication is open and honest (Byock, 1997; Green, 2008). The different perspectives of everyone involved are unlikely to converge without clear com- munication and discussion. Respecting each person’s perspective is basic and greatly helps in creating a good final scenario.
Encouraging people to decide for themselves how the end of their lives should be handled helps people take control of their dying (Hains & Hulbert-Williams, in press). Taking personal control over one’s dying process is a trend occurring even in cultures like Japan that traditionally defer to physician’s opinions (Alden, Merz, & Akashi, 2012). The emergence of final sce- narios as an important consideration fits well with the
emphasis on addressing pain through palliative care, an approach underlying hospice.
The Hospice Option As we have seen, most people would like to die at home among family and friends. An important barrier to this choice is the availability of support systems when the person has a terminal disease. Most people believe they have no choice but to go to a hospital or nursing home. However, another alternative exists. Hospice is an approach to assist dying people emphasizing pain management, or palliative care, and death with dignity (Knee, 2010; Winslow & Meldrum, 2013). The empha- sis in a hospice is on the dying person’s quality of life. This approach grows out of an important distinction between the prolongation of life and the prolongation of death, a distinction important to Jean, the woman we met in the vignette. In a hospice the concern is to make the person as peaceful and comfortable as pos- sible, not to delay an inevitable death. Although medi- cal care is available at a hospice, it is aimed primarily at controlling pain and restoring normal functioning. The approach to care in hospice is called palliative care and is focused on providing relief from pain and other symptoms of disease at any point during the disease process (Reville, 2011).
Modern hospices are modeled after St. Christopher’s Hospice in England, founded in 1967 by Dr. Cicely Saunders. Hospice services are requested only after the person or physician believes no treatment or cure is possible, making the hospice program markedly dif- ferent from hospital or home care. The differences are evident in the principles that underlie hospice care:
Clients and their families are viewed as a unit, clients should be kept free of pain, emotional and social impoverishment must be minimal;
Clients must be encouraged to maintain compe- tencies, conflict resolution and fulfillment of real- istic desires must be assisted; and
Clients must be free to begin or end relationships, an interdisciplinary team approach is used, and staff members must seek to alleviate pain and fear. (Knee, 2010).
Two types of hospices exist: inpatient and outpa- tient. Inpatient hospices provide all care for clients;
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DYING AND BEREAVEMENT 389
outpatient hospices provide services to clients who remain in their own homes. The outpatient variation, when a hospice nurse visits clients in their home, is becoming increasingly popular, largely because more clients can be served at a lower cost. Having hospice services available to people at home is a viable option for many people, especially in helping home-based caregivers cope with loss, but should be provided by specially-trained professionals (Newman, Thompson, & Chandler, 2013).
Hospices do not follow a hospital model of care. The role of the staff in a hospice is not so much to treat the client as it is just to be with the client. A client’s dig- nity is always maintained; often more attention is paid to appearance and personal grooming than to medical tests. Hospice staff members also provide a great deal of support to the client’s family.
Hospice and hospital patients differ in important ways (Knee, 2010). Hospice clients are more mobile, less anxious, and less depressed; spouses visit hos- pice clients more often and participate more in their care; and hospice staff members are perceived as more accessible. Research consistently shows significant improvements in clients’ quality of life occur after hos- pice placement or beginning palliative care (Rocque & Cleary, 2013).
Although the hospice is a valuable alternative for many people, it may not be appropriate for everyone. Those who trust their physician regarding medical care options are more likely to select hospice than those who do not trust their physician, especially among African Americans (Ludke & Smucker, 2007). Most people who select hospice suffer from cancer, AIDS, cardio- vascular disease, pulmonary disease, or a progressive neurological condition such as dementia; two-thirds are over age 65 ; and most are in the last six months of life (Hospice Foundation of America, 2013a).
Needs expressed by staff, family, and clients dif- fer (Hiatt et al., 2007). Staff and family members tend to emphasize pain management, whereas many clients want more attention paid to personal issues, such as spirituality and the process of dying. This difference means the staff and family members may need to ask clients more often what they need instead of making assumptions about what they need.
How do people decide to explore the hospice option? Families need to consider several things
(Hospice Foundation of America, 2013b; Karp & Wood, 2012; Knee, 2010):
Is the person completely informed about the nature and prognosis of his or her condition? Full knowl- edge and the ability to communicate with health care personnel are essential to understanding what hospice has to offer.
What options are available at this point in the progress of the person’s disease? Knowing about all available treatment options is critical. Exploring treatment options also requires health care profes- sionals to be aware of the latest approaches and be willing to disclose them.
What are the person’s expectations, fears, and hopes? Some older adults, like Jean, remember or have heard stories about people who suffered greatly at the end of their lives. This can pro- duce anxiety about one’s own death. Similarly, fears of becoming dependent play an important role in a person’s decision making. Discover- ing and discussing these anxieties helps clarify options.
How well do people in the person’s social network communicate with each other? Talking about death is taboo in many families. In others, intergen- erational communication is difficult or impos- sible. Even in families with good communication, the pending death of a loved relative is difficult. As a result, the dying person may have difficulty expressing his or her wishes. The decision to explore the hospice option is best made when it is discussed openly.
Are family members available to participate actively in terminal care? Hospice relies on family mem- bers to provide much of the care that is supple- mented by professionals and volunteers. We saw in Chapter 11 being a primary caregiver can be highly stressful. Having a family member who is willing to accept this responsibility is essential for the hospice option to work.
Is a high-quality hospice care program available? Hospice programs are not uniformly good. As with any health care provider, patients and fam- ily members must investigate the quality of local hospice programs before making a choice. The
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390 CHAPTER 13
Hospice Foundation of America provides excel- lent material for evaluating a hospice.
Is hospice covered by insurance? Hospice services are reimbursable under Medicare in most cases, but any additional expenses may or may not be covered under other forms of insurance.
Hospice provides an important end-of-life option for many terminally ill people and their families. Moreover, the supportive follow-up services they pro- vide are often used by surviving family and friends. Most important, the success of the hospice option has had important influences on traditional health care. For example, the American Academy of Pain Medicine (2009) published an official position paper advocating the use of medical and behavioral interventions to pro- vide pain management.
Despite the importance of the hospice option for end-of-life decisions, terminally ill persons face the barriers of family reluctance to face the reality of ter- minal illness and participate in the decision-making process and health care providers hindering access to hospice care (Karp & Wood, 2012; Knee, 2010; Mel- hado & Byers, 2011; Reville, 2011).
As the end of life approaches, the most important thing to keep in mind is that the dying person has the right to state-of-the-art approaches to treatment and pain management. Irrespective of the choice of tradi- tional health care or hospice, the wishes of the dying person should be honored, and family members must participate.
Making Your End-of-Life Intentions Known As has been clearly shown, euthanasia raises complex legal, political, and ethical issues. In most jurisdictions, euthanasia is legal only when a person has made known his or her wishes concerning medical intervention. Unfortunately, many people fail to take this step, per- haps because it is difficult to think about such situations or because they do not know the options available to them. Without clear directions, medical personnel may be unable to take a patient’s preferences into account.
There are two ways to make one’s intentions known. In a living will , a person simply states his or her wishes about life support and other treatments. In a health care power of attorney , an individual appoints someone to act as his or her agent for health care decisions
(see Figure 13.3 ). A major purpose of both is to make one’s wishes known about the use of life support inter- ventions in the event the person is unconscious or oth- erwise incapable of expressing them, along with other related end-of-life issues such as organ transplantation and other health care options (Baumann et al., 2011; Castillo et al., 2011). A durable power of attorney for health care has an additional advantage: It names an individual who has the legal authority to speak for the person if necessary.
Although there is considerable support for both mechanisms, there are several problems as well ( Castillo, Williams, Hooper, Sabatino, Weithorn, & Sudore, 2011; Moorman & Inoue, 2013). States vary in their laws relat- ing to advance directives. Many people fail to inform their relatives and physicians about their health care decisions. Others do not tell the person named in a durable power of attorney where the document is kept. Obviously, this puts relatives at a serious disadvantage if decisions concerning the use of life-support systems need to be made.
A living will or a durable power of attorney for health care can be the basis for a “Do Not Resuscitate” medical order. A Do Not Resuscitate (DNR) order means cardiopulmonary resuscitation (CPR) is not started should one’s heart and breathing stop. In the nor- mal course of events, a medical team will immediately try to restore normal heartbeat and respiration. With a DNR order, this treatment is not done. As with living wills and health care power of attorney, it is extremely important to let all appropriate medical personnel know a DNR order is in effect.
Patient Self-Determination and Competency Evaluation. A key factor in making your decisions about health care known, concern your ability to make those decisions for yourself. The Patient Self-Determi- nation Act, passed in 1990, requires most health care facilities to provide information to patients in writing that they have several rights to:
Make their own health care decisions. Accept or refuse medical treatment. Make an advance health care directive.
Patients must be asked if they have an advance direc- tive, and, if so, include it in the medical record. Staff
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DYING AND BEREAVEMENT 391
at the health care facility must receive training about advance directives, and cannot make admissions or treatment decisions based on whether those directives exist.
Although this legal requirement for health care facilities has been in effect for decades, its extension to individual physicians that would have included finan- cial reimbursement for their discussions with patients about these issues was not included in the Affordable Care Act of 2010 due to opposition such discussions would create the equivalent of “death panels” (Pear,
2011). As a result, the opportunity to encourage people to think about what kind of medical care and interven- tion they desire before such situations arise was essen- tially lost.
One major concern regarding end-of-life deci- sions is whether the person is cognitively or legally able to make them (Moye, Sabatino, & Brendel, 2013). There are two types of determination: the capacity to make decisions, that is a clinical determination, and a competency decision, made legally by the court (Wettstein, 2013). With capacity determinations, the
Figure 13.3 p p y Example of a durable power of attorney document for health care decisions.
3. General statement of authority granted.
Except as indicated in section 4 below, I hereby grant to my health care agent named above full power and authority to make health care decisions on my behalf,
including, but not limited to, the following:
A. To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this information;
B. To employ or discharge my health care providers;
C. To consent to and authorize my admission to and discharge from a hospital, nursing or convalescent home, or other institution;
D. To give consent for, to withdraw consent for, or to withhold consent for, X ray, anesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist, or podiatrist. This authorization specifi cally includes the power to consent to measures for
relief of pain.
E. To authorize the withholding or withdrawal of life-sustaining procedures when and if my physician determines that I am terminally ill, permanently in a coma, suffer severe dementia, or am in a persistent vegetative state. Lifesustaining procedures are those forms of medical care that only serve to artifi cially prolong the
dying process and may include mechanical ventilation, dialysis, antibiotics, artifi cial nutrition and hydration, and other forms of medical treatment which sustain,
restore or supplant vital bodily functions. Life-sustaining procedures do not include care necessary to provide comfort or alleviate pain.
I DESIRE THAT MY LIFE NOT BE PROLONGED BY LIFE-SUSTAINING PROCEDURES IF I AM TERMINALLY ILL, PERMANENTLY
IN A COMA, SUFFER SEVERE DEMENTIA, OR AM IN A PERSISTENT VEGETATIVE STATE.
F. To exercise any right I may have to make a disposition of any part or all of my body for medical purposes, to donate my organs, to authorize an autopsy, and to direct the disposition of my remains.
G. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers.
4. Special provisions and limitations.
(Notice: The above grant of power is intended to be as broad as possible so that your health care agent will have authority to make any decisions you could make to obtain or terminate any type of health care. If you wish to limit the scope of your health care agent’s powers, you may do so in this section.)
In exercising the authority to make health care decisions on my behalf, the authority of my health care agent is subject to the following special provisions and
limitations (Here you may include any specific limitations you deem appropriate such as: your own definition of when life-sustaining treatment should be withheld or discontinued, or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs, or unacceptable to you for any other reason.) :
5. Guardianship provision.
If it becomes necessary for a court to appoint a guardian of my person, I nominate my health care agent acting under this document to be the guardian of my person,
to serve without bond or security.
6. Reliance of third parties on health care agent.
A. No person who relies in good faith upon the authority of or any representations by my health care agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions by my health care agent.
Source: North Carolina State University, A&T State University Cooperative Extension.
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392 CHAPTER 13
issue is whether the individual is able to make a deci- sion about specific tasks, and the abilities necessary are subject to measurement. With competency determina- tions, the individual is being judged either with respect to a specific task or in general, and the determination can be made subjectively by the court.
At this point, the case law is limited regarding whether a person who lacks the capacity to make health care decisions can still designate a surrogate to make them on their behalf. This situation is rather common, though, given the tendency for families to not discuss these issues, individual’s reluctance to face the poten- tial need, and the politicization of the conversation in the health care arena. Guidelines for professionals regarding the assessment of competence are available, and they should be aware of the legal issues (Moye et al., 2013; Wettstein, 2013).
Research indicates family members and other sur- rogate decision-makers are often wrong about what patients really want (Moorman & Inoue, 2013). This further emphasizes the critical need to discuss end- of-life issues ahead of time and ensure the appropriate advance directives are in place and key individuals are aware of them.
shock just the same. Bertha thinks about him much of the time and often finds herself making decisions on the basis of “what John would have done” in the same situation.
Each of us suffers many losses over a lifetime. Whenever we lose someone close to us through death or other separation, like Bertha we experience bereave- ment, grief, and mourning. Bereavement is the state or condition caused by loss through death . Grief is the sorrow, hurt, anger, guilt, confusion, and other feelings that arise after suffering a loss . Mourning concerns the ways we express our grief . You can tell people in some cultures are bereaved and in mourning because of the clothing they wear. Mourning is highly influenced by culture. For some, mourning may involve wearing black, attending funerals, and observing an official period of grief; for others, it means drinking, wear- ing white, and marrying the deceased spouse’s sibling. Grief corresponds to the emotional reactions follow- ing loss, whereas mourning is the culturally approved behavioral manifestations of those feelings. Even though mourning rituals may be fairly standard within a culture, how people grieve varies, as we see next. We will also see how Bertha’s reactions are fairly typical of most people.
The Grief Process How do people grieve? What do they experience? Per- haps you already have a good idea about the answers to these questions from your own experience. If so, you already know the process of grieving is a complicated and personal one. Just as there is no right way to die, there is no right way to grieve. Recognizing there are plenty of individual differences, we consider these pat- terns in this section.
The grieving process is often described as reflect- ing many themes and issues people confront that may be expressed through rituals (Norton & Gino, in press). Like the process of dying, grieving does not have clearly demarcated stages through which we pass in a neat sequence, although there are certain issues people must face similar to those faced by dying people. When someone close to us dies, we must reorganize our lives, establish new patterns of behavior, and redefine rela- tionships with family and friends. Indeed, Attig (1996) provided one of the best descriptions of grief when he wrote grief is the process by which we relearn the world.
Adult Development in Action What steps are necessary to ensure that your advance directives about health care are followed?
13.4 Surviving The Loss: The Grieving Process LEARNING OBJECTIVES
How do people experience the grief process? What feelings do grieving people have? How do people cope with grief? What is the difference between normal and
complicated or prolonged grief disorder? What developmental aspects are important in
understanding grief?
After 67 years of marriage, Bertha recently lost her husband. At 90 , Bertha knew neither she nor her hus- band was likely to live much longer, but the death was a
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DYING AND BEREAVEMENT 393
Unlike bereavement, over which we have no con- trol, grief is a process that involves choices in coping, from confronting the reality and emotions to using religion to ease one’s pain (Ivancovich & Wong, 2008; Norton & Gino, in press). From this perspective, grief is an active process when a person must do several things (Worden, 1991):
Acknowledge the reality of the loss . We must over- come the temptation to deny the reality of our loss; we must fully and openly acknowledge it and real- ize it affects every aspect of our life.
Work through the emotional turmoil . We must find effective ways to confront and express the com- plete range of emotions we feel after the loss and must not avoid or repress them.
Adjust to the environment where the deceased is absent . We must define new patterns of living that adjust appropriately and meaningfully to the fact the deceased is not present.
Loosen ties to the deceased . We must free ourselves from the bonds of the deceased in order to reen- gage with our social network. This means finding effective ways to say good-bye.
The notion that grief is an active coping process emphasizes survivors must come to terms with the physical world of things, places, and events as well as our spiritual place in the world; the interpersonal world of interactions with family and friends, the dead, and, in some cases, God; and aspects of our inner selves and our personal experiences (Ivancovich & Wong, 2008; Papa & Litz, 2011). Bertha, the woman in the vignette, is in the middle of this process. Even the matter of deciding what to do with the deceased’s personal effects can be part of this active coping process (Attig, 1996).
In considering the grief process, we must avoid making several mistakes. First, grieving is a highly individual experience (Mallon, 2008; Papa & Litz, 2011). A process that works well for one person may not be the best for someone else. Second, we must not underestimate the amount of time people need to deal with the various issues. To a casual observer, it may appear a survivor is “back to normal” after a few weeks. Actually, it takes much longer to resolve the complex emotional issues faced during bereavement. Research- ers and therapists alike agree a person needs at least a year following the loss to begin recovery, and two years is not uncommon.
Finally, “recovery” may be a misleading term. It is probably more accurate to say we learn to live with our loss rather than we recover from it (Attig, 1996). The impact of the loss of a loved one lasts a long time, per- haps for the rest of one’s life. Still, most people reach a point of moving on with their lives in a reasonable timeframe (Bonanno, 2009; Bonnano, Westphal, & Mancini, 2011).
Recognizing these aspects of grief makes it eas- ier to know what to say and do for bereaved people. Among the most useful things are to simply let the per- son know you are sorry for his or her loss, you are there for support, and mean what you say.
Risk Factors in Grief. Bereavement is a life experi- ence most people have many times, and most people eventually handle it, often better than we might sus- pect (Bonanno, 2009; Bonanno et al., 2011). However, there are some risk factors that make bereavement more difficult. Several of the more important are the mode of death, personal factors (e.g., personality, reli- giosity, age, gender), income, and interpersonal context
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(social support, kinship relationship; Kersting, Brähler, Glaesmer, & Wagner, 2011; Thieleman & Cacciatore, in press).
Most people believe the circumstances or mode of death affects the grief process. A person whose fam- ily member was killed in an automobile accident has a different situation to deal with than a person whose family member died after a long period of suffering with Alzheimer’s disease. It is believed when death is anticipated, people go through a period of anticipatory grief before the death that supposedly serves to buffer the impact of the loss when it does come and to facili- tate recovery (Haley, 2013; Lane, 2007). However, the research evidence for this is mixed. Anticipating the loss of a loved one from cancer or other terminal dis- ease can provide a framework for understanding fam- ily members’ reactions (Coombs, 2010). Not all family members actually experience it, though. However, people who do, tend to disengage from the dying per- son (Haley, 2013; Lane, 2007).
The strength of attachment to the deceased per- son does make a difference in dealing with a sudden as opposed to an unexpected death. Attachment the- ory provides a framework for understanding different reactions (Stroebe & Archer, 2013; Stroebe, Schut, & Boerner, 2010). When the deceased person was one whom the survivor had a strong and close attachment and the loss was sudden, greater grief is experienced (Wayment & Vierthaler, 2002). However, such secure attachment styles tend to result in less depression after the loss because of less guilt over unresolved issues (because there are fewer of them), things not provided (because more were likely provided), and so on.
Few studies of personal risk factors have been done, and few firm conclusions can be drawn. To date there are no consistent findings regarding personality traits that either help buffer people from the effects of bereavement or exacerbate them (Haley, 2013; Stroebe & Archer, 2013; Stroebe et al., 2010). There is some evi- dence to suggest church attendance or spirituality in general helps people deal with bereavement and subse- quent grief through the post-grief period (Bratkovich, 2010; Gordon, 2013). There are, however, consistent findings regarding gender. Men have higher mortality rates following bereavement than women, who have higher rates of depression and complicated grief (dis- cussed later in this section) than men, but the reasons
for these differences are unclear (Kersting et al., 2011). Research also consistently shows older adults suffer the least health consequences following bereavement, with the impact perhaps being strongest for middle-aged adults, but strong social support networks lessen these effects to varying degrees (Papa & Litz, 2011).
Two interpersonal risk factors have been exam- ined: lack of social support and kinship. Studies indicate social support and mastery help buffer the effects of bereavement more for older adults than for middle-aged adults (Haley, 2013; Papa & Litz, 2011). This may change as more support begins to come from online social networks, a medium used more widely by younger and middle-aged adults (Massimi, 2013).
Normal Grief Reactions The feelings experienced during grieving are intense, that not only makes it difficult to cope but can also make a person question her or his own reactions. The feelings involved usually include sadness, denial, anger, loneliness, and guilt.
Many authors refer to the psychological side of com- ing to terms with bereavement as grief work . Whether the loss is ambiguous and lacking closure (e.g., waiting to learn the fate of a missing loved one) or certain (e.g., verification of death through a dead body), people need space and time to grieve (Berns, 2011; Rosenblatt, 2013). Even without personal experience of the death of close family members, people recognize the need to give survivors time to deal with their many feelings. However, American society does not support long periods of grieving, and pressures bereaved individuals to come to “closure” as quickly as possible. That is not how people really feel or want to deal with their grief.
Muller and Thompson (2003) examined people’s experience of grief in a detailed interview study and found five themes. Coping concerns what people do to deal with their loss in terms of what helps them. Affect refers to people’s emotional reactions to the death of their loved one; such as certain topics that serve as emotional triggers for memories of their loved one. Change involves the ways survivors’ lives change as a result of the loss; personal growth (e.g., “I didn’t think I could deal with something that painful, but I did”) is a common experience. Narrative relates to the sto- ries survivors tell about their deceased loved one, that sometimes includes details about the process of the
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DYING AND BEREAVEMENT 395
death. Finally, relationship reflects who the deceased person was and the nature of the ties between that per- son and the survivor. Collectively, these themes indi- cate the experience of grief is complex and involves dealing with one’s feelings as a survivor as well as memories of the deceased person.
How people show their feelings of grief var- ies across ethnic groups (Papa & Litz, 2011). Latino American men show more of their grief behaviorally than do European American men (Sera, 2001). Such differences are also found across cultures. Families in KwaZulu-Natal, South Africa, have a strong desire for closure and need for dealing with the “loneliness of grief ” (Brysiewicz, 2008). In many cultures the bereaved construct a relationship with the person who died, but how this happens differs widely, from “ghosts” to appearances in dreams to connection through prayer (Rosenblatt, 2001).
In addition to psychological grief reactions, there are also physiological ones (McKissock & McKissock, 2012). Physical health may decline, illness may result, and use of health care services may increase. In some cases it is necessary to treat severe depression following bereavement; we consider complicated grief reactions a bit later. Widows report sleep disturbances as well as neurological and circulatory problems ( Kowalski & Bondmass, 2008). Widowers in general report major disruptions in their daily routines (Naef, Ward, Mahrer-Imhof, & Grande, 2013).
In the time following the death of a loved one, dates having personal significance may reintroduce feelings of grief. Holidays such as Thanksgiving or birthdays that were spent with the deceased person may be difficult times. The actual anniversary of the death can be especially troublesome. The term anniversary reaction refers to changes in behavior related to feelings of sadness on this date . Personal experience and research show recurring feelings of sadness or other examples of the anniversary reaction are common in normal grief (Holland & Neimeyer, 2010). Such feelings also accompany remembrances of major catastrophes across cultures, such as Thais remembering the victims of a major flood (Assanang- kornchai et al., 2007).
Most research on how people react to the death of a loved one is cross-sectional. This work shows grief tends to peak within the first six months following the
death of a loved one (Maciejewski, Zhang, Block, & Prigerson, 2007). However, some work has been done to examine how people continue grieving many years after the loss. Some widows show no sign of lessening of grief after five years (Kowalski & Bondmass, 2008). Rosenblatt (1996) reported people still felt the effects of the deaths of family members 50 years after the event. The depth of the emotions over the loss of loved ones never totally went away, as people still cried and felt sad when discussing the loss despite the length of time that had passed. In general, though, people move on with their lives within a relatively short period of time and deal with their feelings reasonably well (Bonanno, 2009; Bonanno et al., 2011).
Coping With Grief Thus far, we considered the behaviors people show when they are dealing with grief. We have also seen these behaviors change over time. How does this hap- pen? How can we explain the grieving process?
Numerous theories have been proposed to account for the grieving process, such as general life-event theories, psychodynamic, attachment, and cognitive process theories (Stroebe & Archer, 2013; Stroebe et al., 2010). All of these approaches to grief are based on more general theories that results in none of them providing an adequate explanation of the grieving pro- cess. Two integrative approaches have been proposed specific to the grief process: the four-component model and the dual-process model of coping with bereavement.
The Four-Component Model. The four-component model proposes understanding grief is based on four things : (1) the context of the loss , referring to the risk factors such as whether the death was expected; (2) continuation of subjective meaning associated with loss , ranging from evaluations of everyday con- cerns to major questions about the meaning of life; (3) changing representations of the lost relationship over time ; and (4) the role of coping and emotion regula- tion processes that cover all coping strategies used to deal with grief (Bonanno et al., 2011; Bonanno, 2009). The four-component model relies heavily on emotion theory, has much in common with the transactional model of stress, and has empirical support. Accord- ing to the four-component model, dealing with grief
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is a complicated process only understood as a complex outcome that unfolds over time.
There are several important implications of this integrative approach. One of the most important is helping a grieving person involves helping them make meaning from the loss (Bratkovich, 2010; Wong, 2008). Second, this model implies encouraging people to express their grief may actually not be helpful. An alternative view, called the grief work as rumination hypothesis , not only rejects the necessity of grief pro- cessing for recovery from loss but views extensive grief processing as a form of rumination that may actually increase distress (Bonanno, Papa, & O’Neill, 2001). Although it may seem people who think obsessively about their loss or who ruminate about it are confront- ing the loss, rumination is actually considered a form of avoidance because the person is not dealing with his or her real feelings and moving on (Robinaugh & McNally, 2013; Stroebe et al., 2007).
One prospective study shows, for instance, bereaved individuals who were not depressed prior to their spouse’s death but then evidenced chroni- cally elevated depression through the first year and a half of bereavement (i.e., a chronic grief pattern) also tended to report more frequently thinking about and talking about their recent loss at the six-month point in bereavement (Bonanno, Wortman, & Neese, 2004). Thus, some bereaved individuals engage in mini- mal grief processing whereas others are predisposed
toward more extensive grief processing. Furthermore, the individuals who engage in minimal grief process- ing will show a relatively favorable grief outcome, whereas those who are predisposed to more exten- sive grief processing tend toward ruminative preoc- cupation and, consequently, to a more prolonged grief course (Bonanno, 2009; Bonanno et al., 2011).
As noted earlier, the grief work as rumination hypothesis also views grief avoidance as an indepen- dent but maladaptive form of coping with loss (Stroebe et al., 2007). In contrast to the traditional perspective, that equates the absence of grief processing with grief avoidance, the grief work as rumination framework assumes resilient individuals are able to minimize processing of a loss through relatively automated pro- cesses, such as distraction or shifting attention toward more positive emotional experiences (Bonanno, 2009; Bonanno et al., 2011). The grief work as rumination framework argues the deliberate avoidance or suppres- sion of grief represents a less effective form of coping (Wegner & Gold, 1995) that exacerbates rather than minimizes the experience of grief (Bonanno, 2009; Bonanno et al., 2011).
The Spotlight on Research feature explores grief work regarding the loss of a spouse and the loss of a child in two cultures, the United States and China. As you read it, pay special attention to the question of whether encouraging people to express and deal with their grief is necessarily a good idea.
HOW DO WE KNOW?: | GRIEF PROCESSING AND AVOIDANCE IN THE UNITED STATES AND CHINA Who were the investigators and what was the aim of the study? Bonanno and colleagues (2005) noted grief following the loss of a loved one often tends to be denied. However, research evidence related to posi- tive benefits of resolving grief is largely lacking. Thus, whether unresolved grief is “bad” remains an open issue. Likewise, cross-cultural evidence is also lacking.
How did the investigators measure the topic of inter- est? Collaborative meetings between U.S. and Chinese researchers resulted in a 13 -item grief processing scale and a 7 -item grief avoidance scale, with both English and Mandarin Chinese versions. Self-reported psychological symptoms and physical health were also collected.
Who were the participants in the study? Adults under age 66 who had experienced the loss of either a spouse or child approximately four months prior to the start of data collection were asked to participate through solicitation letters. Participants were from either the metropolitan areas of Washington, D.C., or Nanjing, Jiangsu Province in China.
What was the design of the study? Two sets of measures were collected at approximately 4 months and 18 months after the loss.
Were there ethical concerns in the study? Because participation was voluntary, there were no ethical concerns.
What were the results? Consistent with the grief work as rumination view, scores on the two grief measures were uncorrelated. Overall, women tended to show more grief processing than men, and grief processing decreased over time. As you can see in
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DYING AND BEREAVEMENT 397
The Dual Process Model. The dual process model (DPM) of coping with bereavement integrates exist- ing ideas regarding stressors (Stroebe & Archer, 2013; Stroebe et al., 2010). As shown in Figure 13.5 , the DPM defines two broad types of stressors. Loss-oriented stressors concern the loss itself, such as the grief work that needs to be done. Restoration-oriented stressors are those that involve adapting to the survivor’s new life sit- uation, such as building new relationships and finding new activities. The DPM proposes dealing with these stressors is a dynamic process, as indicated by the lines connecting them in the figure. This is a distinguishing feature of DPM. It shows how bereaved people cycle back and forth between dealing mostly with grief and trying to move on with life. At times the emphasis will be on grief; at other times on moving forward.
The DPM captures well the process bereaved people themselves report—at times they are nearly overcome with grief, while at other times they handle life well. The DPM also helps us understand how, over time, people come to a balance between the long-term effects of bereavement and the need to live life. Under- standing how people handle grief requires understand- ing of the various context that people live and interact with others (Sandler, Wolchik, & Ayers, 2008).
Complicated or Prolonged Grief Disorder Not everyone is able to cope with grief well and begin rebuilding a life. Sometimes the feelings of hurt, loneliness, and guilt are so overwhelming they become the focus of the survivor’s life to such an extent there is never any closure and the grief
Figure 13.4 , Chinese participants reported more grief processing and grief avoidance than U.S. participants at the first time of measurement, but differences disappeared by the second measurement for grief processing.
What did the investigators conclude? Based on converging results from the United States and China,
the researchers concluded the data supported the grief work as rumination view. The results support the notion excessive processing of grief may actually increase a bereaved person’s stress and feelings of discomfort rather than being helpful. These findings contradict the idea people should be encouraged to work through their grief and doing so will always be helpful.
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Figure 13.4 Grief processing and deliberate grief avoidance across time in China and the United States. Source: From Bonanno et al. (2005), p. 92.
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continues to interfere indefinitely with one’s ability to function. When this occurs, individuals are viewed as having complicated or prolonged grief disorder , and is distinguished from depression and normal grief in terms of separation distress and traumatic distress (Stroebe, Schut, van den Bout, 2012). Symptoms of separation distress include preoccupation with the deceased to the point it interferes with everyday func- tioning, upsetting memories of the deceased, longing and searching for the deceased, and isolation follow- ing the loss. Symptoms of traumatic distress include feeling disbelief about the death, mistrust, anger, and detachment from others as a result of the death, feel- ing shocked by the death, and the experience of physi- cal presence of the deceased .
Complicated grief forms a separate set of symp- toms from depression (Stroebe et al., 2012). Individu- als experiencing complicated grief report high levels of separation distress (such as yearning, pining, or longing for the deceased person), along with specific cognitive, emotional, or behavioral indicators (such as avoiding reminders of the deceased, diminished sense of self, difficulty in accepting the loss, feeling bitter or angry), as well as increased morbidity, increased smok- ing and substance abuse, and difficulties with family and other social relationships. Similar distinctions have been made between complicated or prolonged grief disorder and anxiety disorders.
Adult Developmental Aspects of Grief Dealing with the loss of a loved one is never easy. How we deal with such losses as adults depends somewhat on the nature of the loss and our age and experience with death.
Special Challenges in Young Adulthood. Because young adults are just beginning to pursue the fam- ily, career, and personal goals they have set, they tend to be more intense in their feelings toward death. When asked how they feel about death, young adults report a strong sense those who die at this point in their lives would be cheated out of their future (Attig, 1996). Complicated grief is relatively common (Mash, Fullerton, & Ursano, in press)
Wrenn (1999) relates one of the challenges faced by bereaved college students is learning “how to respond to people who ignore their grief, or who tell them they need to get on with life and it’s not good for them to continue to grieve”( 134 ). College students have a need to express their grief like other bereaved people do, so providing them the opportunity to do so is crucial (Fajgenbaum, Chesson, & Lanzl, 2012; Servaty-Seib & Taub, 2010).
Experiencing the loss of one’s partner in young adulthood can be traumatic, not only because of the loss itself but also because such loss is unexpected. As Trish Straine, a 32 -year-old widow whose husband was killed in the World Trade Center attack put it: “I sud- denly thought, ‘I’m a widow.’ Then I said to myself, ‘A widow? That’s an older woman, who’s dressed in black. It’s certainly not a 32 -year-old like me’” (Lieber, 2001). One of the most difficult aspects for young widows and widowers is they must deal with both their own and their young children’s grief and provide the sup- port their children need and that can be extremely dif- ficult. “Every time I look at my children, I’m reminded of Mark,” said Stacey, a 35 -year-old widow whose hus- band died of bone cancer. “And people don’t want to hear you say you don’t feel like moving on, even though there is great pressure from them to do that.”
Figure 13.5 The dual process model of coping with bereavement shows the relation between dealing with the stresses of the loss itself (loss-oriented) and moving on with one's life (restoration-oriented). Source: M. Stroebe & Schut (2001).
Loss-oriented
Everyday life experience
Grief work
Intrusion of grief
Breaking bonds/ties/ relocation of the deceased person Denial/avoidance of restoration changes
Denial/avoidance of grief New roles/identities/ relationships
Restoration-oriented
Attending to life changes
Doing new things
Distraction from grief
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DYING AND BEREAVEMENT 399
Stacey is a good example of what research shows: Young adult widows report their level of grief does not typically diminish significantly until five to ten years after the loss, and they maintain strong attachments to their deceased husbands for at least that long (Derman, 2000). Young Canadian widows also report intense feelings and a desire to stay connected through memo- ries (Lowe & McClement, 2010–2011).
Death of One’s Child. The death of one’s child, for most parents, brings unimaginable grief (Stroebe, Finkenauer, Wijngaards-de Meij, Schut, van den Bout, & Stroebe, 2013). Because children are not supposed to die before their parents, it is as if the natural order of things has been violated, shaking parents to their core (Rubin & Malkinson, 2001). Mourning is always intense; some parents never recover or reconcile them- selves to the death of their child and may terminate their relationship with each other (Rosenbaum, Smith, & Zollfrank, 2011). The intensity of feelings is due to the strong parent–child bond that begins before birth and lasts a lifetime (Maple, Edwards, Plummer, & Minichiello, 2010; Rosenbaum et al., 2011).
Young parents who lose a child unexpectedly report high anxiety, a more negative view of the world, and much guilt, that results in a devastating experi- ence (Seyda & Fitzsimons, 2010). The most over- looked losses of a child are those that happen through stillbirth, miscarriage, abortion, or neonatal death (Earle, Komaromy, & Layne, 2012; Rosenbaum, Smith, & Zollfrank 2011). Attachment to the child begins before birth, especially for mothers, so the loss hurts deeply. For this reason, ritual is extremely important to
acknowledge the death and validate parents’ feelings of grief (Kobler, Limbo, & Kavanaugh, 2007).
Yet parents who experience this type of loss are expected to recover quickly. The lived experience of parents tells a different story (Seyda & Fitzsimons, 2010). These parents talk about a life-changing event, and report a deep sense of loss and hurt, especially when others do not understand their feelings. Worst of all, if societal expectations for quick recovery are not met the parents may be subjected to unfeeling comments. As one mother notes, parents often just wish somebody would acknowledge the loss (Okonski, 1996).
The loss of a young adult child for a middle-aged parent is experienced differently but is equally dev- astating (Maple, Edwards, Minichiello, & Plummer, 2013; Schneider, 2013). Parents who lost sons in wars (Rubin, Malkinson, & Witztum, 2012) and in traf- fic accidents (Shalev, 1999) still report strong feelings of anxiety, problems in functioning, and difficulties in relationships with both surviving siblings and the deceased as long as 13 years after the loss.
Death of One’s Parent. Most parents die after their children are grown. But whenever parental death occurs, it hurts. Losing a parent in adulthood is a rite of passage as one is transformed from being a “son” or “daughter” to being “without parents” (Abrams, 2013; Edwards, 2006). We, the children, are now next in line.
The loss of a parent is a significant one. For young adult women transitioning to motherhood, losing their own mother during adolescence raises many feelings, such as deep loss at not being able to share their preg- nancies with their mothers and fear of dying young themselves (Franceschi, 2005). Middle-aged women who lose a parent report feeling a complex set of emo- tions (Westbrook, 2002): they have intense emotional feelings of both loss and freedom, they remember both positive and negative aspects of their parent, and they experience shifts in their own sense of self.
The feelings accompanying the loss of an older parent reflect a sense of letting go, loss of a buffer against death, better acceptance of one’s own eventual death, and a sense of relief the parent’s suffering is over (Abrams, 2013; Igarashi et al., 2013). Yet, if the par- ent died from a cause, such as Alzheimer’s disease, that involves the loss of the parent–child relationship along the way, then bodily death can feel like the second time
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the parent died (Shaw, 2007). Whether the adult child now tries to separate from the deceased parent’s expec- tations or finds comfort in the memories, the impact of the loss is great.
Conclusion Death is not as pleasant a topic as children’s play or occupational development. It’s not something we can go to college to master. What it represents to many people is the end of their existence, and that is a scary prospect. But because we all share in this fear at some level, each of us is equipped to provide support and comfort for grieving survivors.
Death is the last life-cycle force we encounter, the ultimate triumph of biological forces limit the length of life. Yet the same psychological and social forces so influential throughout life help us deal with death, either our own or someone else’s. As we come to the end of our life journey, we understand death through an interaction of psychological forces—such as coping skills and intellectual and emotional understanding of death—and the sociocultural forces expressed in a par- ticular society’s traditions and rituals.
Learning about and dealing with death is clearly a developmental process across the life span that fits well in the biopsychosocial framework. Most apparent is that biological forces are essential to understanding death. The definition of death is based on whether cer- tain biological functions are present; these same defi- nitions create numerous ethical dilemmas that must be dealt with psychologically and socioculturally. Life- cycle forces also play a key role. We have seen, depend- ing on a person’s age, the concept of death has varied meanings beyond the mere cessation of life.
How a person’s understanding of death develops is also the result of psychological forces. As the ability to think and reflect undergoes fundamental change, the view of death changes from a mostly magical approach to one that can be transcendent and transforming. As we have seen, people who face their own immi- nent death experience certain feelings. Having gained experience through the deaths of friends and relatives, a person’s level of comfort with his or her own death may increase. Such personal experience may also come about by sharing the rituals defined through sociocul- tural forces. People observe how others deal with death and how the culture sets the tone and prescribes behav- ior for survivors. The combined action of forces also determines how they cope with the grief that accom- panies the loss of someone close. Psychologically, con- fronting grief depends on many things, including the quality of the support system we have.
Thus, just as the beginning of life represents a complex interaction of biological, psychological, sociocultural, and life-cycle factors, so does death. What people believe about what follows after death is also an interaction of these factors. So, as we bring our study of human development to a close, we end where we began: What we experience in our lives cannot be understood from only a single perspective.
Adult Development in Action How is grief a product of the biopsychosocial model? How would you use the biopsychosocial model to create a support group for bereaved people?
SOCIAL POLICY IMPLICATIONS As you probably surmised from the text, issues sur- rounding death and health care can be extremely controversial. Although the use of life-sustaining tech- nologies (such as life support machines) is widespread, and the courts ensured individuals and designated oth- ers can make decisions about the extent and types of care received, the emotion attached to these events and decisions is high. Because most people do not spend time thinking about what they truly want and then making
others, including their health care professional, aware of those decisions, most are left trying to make them in the midst of a health care crisis. To make matters worse, if a person has not made any plans known, and is not in a condition to make them (e.g., is unconscious), steps may be taken that would not have been welcomed had those decisions been made an made known.
Discussions in the chapter referenced two key events that brought end-of-life decisions to the forefront of public discourse. The first was the Terri Schiavo case in 2005 that raised the issue of when
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DYING AND BEREAVEMENT 401
by stopping nutrition). It is essential people make their wishes known through either a health care power of attorney or a living will.
What issues surround the costs of life-sustaining care? The personal and financial costs of prolonging life
when the patient would have preferred another option are significant.
13.2 Thinking About Death: Personal Aspects
How do feelings about death change over adulthood? Young adults report a sense of being cheated by
death. Cognitive developmental level is impor- tant for understanding how young adults view death.
Middle-aged adults begin to confront their own mortality and undergo a change in their sense of time lived and time until death.
Older adults are more accepting of death.
How do people deal with their own death? Kübler-Ross’s approach includes five stages: denial,
anger, bargaining, depression, and acceptance. People may be in more than one stage at a time and do not necessarily go through them in order.
A contextual theory of dying emphasizes the tasks a dying person must face. Four dimensions of these tasks have been identified: bodily needs, psycho- logical security, interpersonal attachments, and
intervention is allowed to end and who can make that decision when the patient had no advance directive, and the second was the debate in 2009 in the midst of Congressional consideration of the Affordable Care Act that raised the specter of “death panels.”
The core social policy issue facing us is the extent individuals have the right to make their own decisions about care, even when that decision is contrary to medi- cal advice; how to know whether that decision is made freely by a capable, competent person; whether physi- cians’ declarations of brain death are accurate; and the extent a government has an interest in the decision, espe- cially if public funds are used in the care being provided or contemplated. These are quite complex issues that also extend into people’s private belief structures, particularly religious/spiritual beliefs in matters of life and death.
Medically, the issues are complicated, too. To maxi- mize the success of organ transplants, individuals may need to be kept on life support until the organs are ready to be taken. Is that ethical? Does that violate
religious beliefs? Does the potential organ recipient have anything to say about the decision?
The current situation in the United States is that physicians are not provided reimbursement under certain medical insurance plans (e.g., Medicare) for taking the time to discuss end-of-life issues with their patients. This means these critical decisions and discus- sions often remain unmade and not held. The conse- quences are serious—individuals and families are then put in the situation of having to make them in crisis, when the time to reflect on the various options is unlikely to be available.
Clearly, more open discussion about end-of-life issues need to be held and policies more reflective of the reality of the complexity of the issues need to be created. With the aging of the baby boom generation, more families than ever will be faced with the inevi- table: having to decide whether they themselves, or a close family member, dies with dignity or has his or her life needlessly prolonged.
Summary 13.1 Definitions and Ethical Issues
How is death defined? Death is a difficult concept to define precisely. Dif-
ferent cultures have different meanings for death. Among the meanings in Western culture are images, statistics, events, state of being, analogy, mystery, boundary, basis for anxiety, and reward or punishment.
What legal and medical criteria are used to determine when death occurs?
For many centuries, a clinical definition of death was used: the absence of a heartbeat and respi- ration. Currently, whole-brain death is the most widely used definition. It is based on several highly specific criteria, including brain activity and responses to specific stimuli.
What are the ethical dilemmas surrounding euthanasia?
Two types of euthanasia are distinguished. Active euthanasia consists of deliberately ending some- one’s life, such as turning off a life-support sys- tem. Physician-assisted suicide is a controversial issue and a form of active euthanasia. Passive euthanasia is ending someone’s life by withhold- ing some type of intervention or treatment (e.g.,
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402 CHAPTER 13
spiritual energy and hope. A contextual theory incorporates differences in reasons people die and the places people die.
What is death anxiety, and how do people show it? Most people exhibit some degree of anxiety about
death, even though it is difficult to define and measure. Individual difference variables include gender, religiosity, age, ethnicity, and occupation. Death anxiety may have some benefits.
The main ways death anxiety is shown are by avoid- ing death (e.g., refusing to go to funerals) and deliberately challenging it (e.g., engaging in dan- gerous sports).
Several ways to deal with anxiety exist: living life to the fullest, personal reflection, and education. Death education has been shown to be extremely effective.
13.3 End-of-Life Issues
How do people deal with end-of-life issues and create a final scenario?
Managing the final aspects of life, after-death disposition of the body, memorial services, and distribution of assets are important end-of-life issues. Making choices about what people want and do not want done constitute making a final scenario.
What is hospice? The goal of a hospice is to maintain the quality of
life and manage the pain of terminally ill patients. Hospice clients typically have cancer, AIDS, or a progressive neurological disorder. Family mem- bers tend to stay involved in the care of hospice clients.
How does one make one’s end-of-life desires and decisions known?
End-of-life decisions are made know most often through a living will, health care power of attor- ney, or a Do Not Resuscitate order. It is important family and health care professionals are aware of these decisions. The Patient Self-Determination Act requires health care facilities to inform patients of these rights.
13.4 Surviving the Loss: The Grieving Process
How do people experience the grief process? Grief is an active process of coping with loss.
Four aspects of grieving must be confronted:
the reality of the loss, the emotional turmoil, adjusting to the environment, and loosening the ties with the deceased. When death is expected, survivors go through anticipatory grief; unex- pected death is usually more difficult for people to handle.
What feelings do grieving people have? Dealing with grief, called grief work , usually takes
at least one to two years. Grief is equally intense for both expected and unexpected death, but it may begin before the actual death when the patient has a terminal illness. Normal grief reac- tions include sorrow, sadness, denial, disbelief, guilt, and anniversary reactions.
How do people cope with grief? In terms of dealing with normal grief, middle-aged
adults have the most difficult time. Poor copers tend to have low self-esteem before losing a loved one.
What is the difference between normal and complicated or prolonged grief?
The four-component model proposes the grief pro- cess is described by context of the loss, continua- tion of subjective meaning associated with the loss, changing representations of the lost relationship over time, and the role of coping and emotion- regulation processes.
The dual process model of coping with bereave- ment focuses on loss-oriented and restoration-ori- ented stressors.
Prolonged grief involves symptoms of separation distress and traumatic distress. Excessive guilt and self-blame are common manifestations of trau- matic grief.
What developmental aspects are important in understanding grief?
Young and middle-aged adults usually have intense feelings about death. Attachment theory provides a useful framework for understanding these feel- ings.
Midlife is a time when people usually deal with the death of their parents and confront their own mor- tality.
The death of one’s child is especially difficult to cope with.
The death of one’s parent deprives an adult of many important things, and the feelings accompa- nying it are often complex.
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DYING AND BEREAVEMENT 403
Review Questions 13.1 Definitions and Ethical Issues
What are the three legal criteria for death? What are the criteria necessary for brain death? What is bioethics, and what kinds of issues does it
deal with? What are the types of euthanasia? How do they
differ? How do the personal and financial costs of life-
sustaining treatment affect health care decisions?
13.2 Thinking about Death: Personal Aspects How do cognitive development and issues at
midlife influence feelings about death? Describe Kübler-Ross’s concepts of dying. How do
people progress through the different feelings? What is necessary for creating a contextual theory
of dying? What is death anxiety? What factors influence
death anxiety? How does it relate to terror man- agement theory?
How do people demonstrate death anxiety? How do people learn to deal with death anxiety?
13.3 End-of-Life Issues What are end-of-life issues? How do people create a final scenario? What is a hospice? How does hospice care differ
from hospital care? What are the major ways that people inform others
of their end-of-life decisions?
13.4 Survivors: The Grieving Process What is meant by grief, bereavement, and mourn-
ing? What is the process of grief? What are the risk fac-
tors associated with grief? What are normal grief reactions and grief work? How does grief change over time? What is the four component model of grief? What is the dual process model of grief? What is the grief-work-as-rumination hypothesis? What are complicated or prolonged grief reactions? How do adults of different ages deal with different
types of loss?
INTEGRATING CONCEPTS IN DEVELOPMENT What effect do you think being at different levels
of cognitive development has on people’s thinking about death?
What parallels are there between the stages of dying and the experience of grief? Why do you think they may be similar?
How can we use the study of death, dying, bereave- ment, and grief to provide insights into the psycho- logical development of people across adulthood?
KEY TERMS active euthanasia The deliberate ending of someone’s life.
anniversary reaction Changes in behavior related to feelings of sadness on the anniversary date of a loss.
anticipatory grief Grief experienced during the period before an expected death occurs that supposedly serves to buffer the impact of the loss when it does come and to facilitate recovery.
bereavement The state or condition caused by loss through death.
bioethics Study of the interface between human values and technological advances in health and life sciences.
clinical death Lack of heartbeat and respiration.
complicated or prolonged grief disorder Expression of grief that is distinguished from depression and from normal grief in terms of separation distress and trau- matic distress.
death anxiety People’s anxiety or even fear of death and dying.
Do Not Resuscitate (DNR) order A medical order that means cardiopulmonary resuscitation (CPR) is not started should one’s heart and breathing stop.
dual-process model (DPM) View of coping with bereavement that integrates loss-oriented stressors and restoration-oriented stressors.
end-of-life issues Issues pertaining to the manage- ment of the final phase of life, after-death disposition of their body, memorial services, and distribution of assets.
euthanasia The practice of ending life for reasons of mercy.
final scenario Making one’s choices known about how they do and do not want their lives to end.
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404 CHAPTER 13
persistent vegetative state Situation in which a person’s cortical functioning ceases while brainstem activity continues.
physician-assisted suicide Process in which physicians provide dying patients with a fatal dose of medication the patient self-administers.
separation distress Expression of complicated or pro- longed grief disorder that includes preoccupation with the deceased to the point it interferes with everyday functioning, upsetting memories of the deceased, longing and searching for the deceased, and isolation following the loss.
terror management theory Addresses the issue of why people engage in certain behaviors to achieve particu- lar psychological states based on their deeply rooted concerns about mortality.
thanatology The study of death, dying, grief, bereave- ment, and social attitudes toward these issues.
traumatic distress Expression of complicated or pro- longed grief disorder that includes feeling disbelief about the death, mistrust, anger, and detachment from others as a result of the death, feeling shocked by the death, and the experience of physical presence of the deceased.
whole-brain death Death that is declared only when the deceased meets eight criteria established in 1981.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
four-component model Model of grief that understanding grief is based on (1) the context of the loss; (2) continuation of subjective meaning associ- ated with loss; (3) changing representations of the lost relationship over time; and (4) the role of coping and emotion regulation processes.
grief The sorrow, hurt, anger, guilt, confusion, and other feelings that arise after suffering a loss.
grief work The psychological side of coming to terms with bereavement.
grief work as rumination hypothesis An approach that not only rejects the necessity of grief process- ing for recovery from loss but views extensive grief processing as a form of rumination that may actually increase distress.
health care power of attorney A document in which an individual appoints someone to act as his or her agent for health care decisions.
hospice An approach to assisting dying people that emphasizes pain management, or palliative care, and death with dignity.
living will A document in which a person states his or her wishes about life support and other treatments.
mourning The ways in which we express our grief.
palliative care Care that is focused on providing relief from pain and other symptoms of disease at any point during the disease process.
passive euthanasia Allowing a person to die by with- holding available treatment.
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Successful Aging
14.1 DEMOGRAPHIC TRENDS AND SOCIAL POLICY Demographic Trends: 2030 • Social Security and Medicare • Current Controversies: What to Do about Social Security and Medicare
14.2 HEALTH ISSUES AND QUALITY OF LIFE Health Promotion and Quality of Life • A Framework for Maintaining and Enhancing Competence • Health Promotion and Disease Prevention • Lifestyle Factors
14.3 SUCCESSFUL AGING Discovering Development: What Is Successful Aging? • Approaches to Successful Aging • Critiques of Successful Aging Framework • Epilogue
Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources
Chapter 14
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406 CHAPTER 14
Welcome to your future. In this epilogue, we take a different perspective on aging. Based on what we know now about older adults and the process of aging, we look to our own future. We consider what society must do to keep the social programs we have come to rely on. We consider what each of us can do to keep our- selves in the best health possible in order to delay or even prevent some of the negative aspects of aging. We take a look at how the baby boom- ers will change everything from how older adults are viewed to the coming enormous pressure on governmental resources. We also look around the corner and ahead a few decades to preview what may be in store for current young adults when they reach late life.
Aging today and in the future is not what it was even a few years ago. Technical advances have and will continue to make commonplace what is only science fiction today. For example, it is likely we will get our annual physical examination remotely, be in classes or meetings led by some- one’s interactive holographic projection when they are in another place, and may meet many of our friends through only Skype or FaceTime. Medicine will make advances such as offering genetic inter- ventions that cure dementia and cancer, offering the possibility of much longer average life spans. It is a future with many more support structures and systems for older adults. It will be an interesting experience, to say the least.
For now, though, we must be content with working with what we do and do not know. Throughout this book we made predictions about this future and guessed how older people may fare. Some of these predictions are not so happy; as many people live to an old age, there will be greater need for long-term care. Whether we will be able to afford to provide the care for them is much in doubt. Other aspects of the future may be more positive; for instance, as many people live to older ages there will be a larger pool of older workers to balance the labor force. These predictions represent our best guess about what life will be like in the next few decades, based on what we know now and what is likely to happen if we continue down our cur- rent path.
The purpose of this epilogue is to pull together several crucial issues facing gerontolo- gists as we move through the 21 st century and to illustrate how we can set the best stage for our own aging. This survey will not be exhaustive; rather, we focus on two things: points singled out for special concern and areas where major advances may have a dramatic impact on our own development.
14.1 Demographic Trends and Social Policy LEARNING OBJECTIVES
What key demographic changes will occur by 2030?
What are the challenges facing Social Security and Medicare?
Nancy, a 35 -year-old new employee at a market- ing and public relations firm, was flipping through the company’s benefits package. When it came to the retirement plan, she commented to the human resources
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SUCCESSFUL AGING 407
person, “I guess I better pay attention. I don’t think Social Security and Medicare will be there for me when the time comes.”
Nancy isn’t alone. Many younger adults in the United States do not believe Social Security, Medicare, or other government programs will be in existence by the time they get old enough to qualify for them. Demographic and financial trends support this pes- simistic view. As we will show, the baby-boom gen- eration, coupled with structural problems in Social Security and Medicare, give young adults good reasons to be concerned.
Demographic Trends: 2030 In Chapter 1 , we noted several trends in the population of the United States and the rest of the world during the upcoming century. These trends are not likely to change in the foreseeable future. Changes in the com- position of the older adult population contribute to potentially critical issues that will emerge over the next few decades. Keep in mind the baby boomers represent the largest generation ever to reach older adulthood. Generation X, the group right behind them, is much smaller. Although larger than Gen-X, the Millennials will still feel the brunt of the effects of aging boomers. One especially important area concerns the potential for intergenerational conflict.
Because the resources and roles in a society are never divided equally among different age groups, the potential for conflict always exists. One well-known intergenerational conflict is between adolescents and their parents. Less well known is the potential for con- flict between young/middle-aged adults and older adults. This type of conflict has not traditionally been a source of serious problems in society, for several reasons: Older adults made up a small proportion of the population, family ties between adult children and their parents worked against conflict, and middle- aged people were hesitant to withdraw support from programs for older adults. Despite these potent forces protecting against conflict, the situation is changing. The controversy over the rate of growth of Medicare and Social Security and the proportion they represent of the federal budget would have been unthinkable just a few years earlier.
To see more clearly how these changing demo- graphics will have an enormous effect on society at
large and on the programs that target older adults, let us project forward to the year 2030, when the last of the baby boomers reach age 65 . Between now and 2030, the following changes will have set in:
The proportion of older adults in the United States will nearly double.
Older adults will be more educated, politically sophisticated, and organized than past genera- tions. They will be familiar with life in a highly complex society where one must learn to deal with (and have little tolerance for) bureaucracies and they will be proficient users of the Internet and technology in general.
Older adults will expect to keep their affluent life- style, Social Security benefits, Medicare/health care benefits, and other benefits accrued through- out their adult life. A comfortable retirement will be viewed as a right, not a privilege. However, they will not, on average, have the financial savings necessary to support those expectations.
The dependency ratio will change. The depen- dency ratio reflects the number of people under age 15 and over age 64 in a country. The depen- dency ratio provides insight into the relative number of people who have to provide the finan- cial support for others not as able to do so. The lower the number, the more workers are needed to pay taxes to provide the revenue for social sup- port programs.
As shown in Figure 14.1 , the dependency ratio for developed countries is about to shift dramatically com- pared to what happened while the baby boomers were growing up and working. For the United States, this plays out most visibly in funding for Social Security and Medicare.
For example, the ratio of workers to retirees will fall from its current level of roughly 3 : 1 to 2 : 1 . This means to maintain the level of benefits in pro- grams such as Social Security, the working members of society will have to pay significantly higher taxes than workers do now. This is because Social Secu- rity is a pay-as-you-go system so the money collected from workers today is used to pay current retirees. Contrary to popular belief, Social Security is not a savings plan. Whether policymakers will make the
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408 CHAPTER 14
South Korea
Demographic cliff
Change in total dependency ratio*, 1960−2010 and 2010−2060, respectively (in %)
Slovakia
Czech Republic
Poland
Slovenia
Ireland
United Kingdom
Sweden
Belgium
Denmark
United States
France
Turkey
Indonesia
Mexico
Argentina
Saudi Arabia
Israel
South Africa
*Persons aged <15 & 65+ per person aged 15−64
India
Brazil
Norway
New Zealand
Finland
Netherlands
Australia
Iceland
Luxembourg
Estonia
Chile
Greece
Italy
Hungary
Germany
Canada
Japan
Austria
Portugal
China
Russia
Spain
Switzerland
−60 −40 −20 0 20 40 60 80 100 120 140
1960−2010
2010−2060
Figure 14.1 Projected change in dependency ratio 1960–2060. Source: United Nations Population Division, World Population Prospects: The 2010 Revision.
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SUCCESSFUL AGING 409
necessary changes to maintain benefits that citizens came to view as entitlements remains to be seen. We take a closer look at both Social Security and Medicare later.
The increase in divorce that has occurred over the past few decades may result in a lowered sense of obligation on the part of middle-aged adults toward parents or step parents who were not involved in their upbringing or who the adult child feels disrespected the other parent. Should this lowered sense of obligation result it is likely fewer older adults will have family members available to care for them, placing a significantly greater bur- den on society for care.
The rapid increase in the number of ethnic minor- ity older adults compared to European American older adults will force a reconsideration of issues such as discrimination and access to health care, goods, and services, as well as provide a much richer and broader understanding of the aging process.
No one knows for certain what society will be like by 2030. However, the changes we noted in demo- graphic trends suggest a need for taking action now. Two areas facing the most challenge are Social Security and Medicare. Let’s take a look at these to understand why they face trouble.
Social Security and Medicare Without doubt, the 20 th and the beginning of the 21 st centuries saw a dramatic improvement in the everyday lives of older adults in industrialized countries. The increase in the number of older adults and their gain in political power, coupled with increased numbers of social programs addressing issues specifically involv- ing older adults, created unprecedented gains for the average older person and changed the way they are viewed in society (Giele, 2013).
As you can see in Figure 14.2 , the economic well- being of the majority of older adults has never been better than it is currently. In 1959, 35 % of older adults were below the federal poverty line compared to only 9 % in 2010 (AgingStats.gov, 2012a).
Whether this downward trend in poverty rates will continue remains to be seen. The baby boomers complicate things (National Academy of Social Insur- ance, 2012). They will be the first generation since the inception of Social Security in the mid-1930s to face a long average life span without the reality of corporate- provided pensions, relatively modest Social Security payments, little personal savings on average, and high projected health care costs during their late life. Those with the financial resources may well prosper; others will drive the costs of social support programs much higher, forcing difficult social policy decisions about
Figure 14.2 Poverty rates in the United States by age group, 1959–2010. Source: U.S. Census Bureau, Current Population Survey, Annual Society and Economic Supplement, 1960–2007.
65 and over
18–64
Under 18
2006 2004199919941989198419791974196919641959
0
10
20
30
40
50
60
70
80
90
100 Percent
Data are not available from 1960–1965 for the 18–64 and 65 and over age groups. Reference population: These data refer to the civilian noninstitutionalized population.
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410 CHAPTER 14
how much base financial support is necessary and affordable.
The Political Landscape . Beginning in the 1970s, older adults began to be portrayed as scapegoats in the political debates concerning government resources. Part of the reason was due to the tremendous growth in the amount and proportion of federal dollars expended on benefits to them, such as through the increase of benefits paid from Social Security during the 1970s (Crown, 2001). At that time in history, older adults were also portrayed as highly politically active, fiscally conservative, and selfish (Fairlie, 1988; Gibbs, 1988; Smith, 1992). The health care reform debate of the early 1990s focused attention on the spiraling costs of care for older adults that were projected to bankrupt the federal budget if left uncontrolled (Binstock, 1999). This theme would echo for decades.
It was in this context the U.S. Congress began mak- ing substantive changes in the benefits for older adults on the grounds of intergenerational fairness. Beginning in 1983, Congress has made several changes in Social Security, Medicare, the Older Americans Act, and other programs and policies. Some of these changes reduced benefits to wealthy older adults, changed eli- gibility rules (e.g., age at which one is eligible for full benefits), whereas others provided targeted benefits for poor older adults, all of which had an effect on how older adults are viewed (Binstock, 1999; Polivka, 2010).
The aging of the baby boomers presents difficult and expensive problems (Office of Management and Budget, 2013). In fiscal year 2014, President Obama proposed federal spending on Social Security and Medicare alone at over $ 1.38 trillion, just over a third
of the total budget. In terms of actual spending, in fiscal year 2011, they accounted for 36 % of all federal spending. Considering baby boomers have only begun to collect these benefits, you get the sense of urgency felt by elected officials.
If spending patterns do not change, by 2030 (when most of the baby boomers have reached old age) expenditures for Social Security and Medicare alone are projected to consume roughly 12 % of the entire gross domestic product (GDP) of the United States (Congressional Budget Office, 2012a). Without major reforms in these programs, that will increase to over 14 % by 2050. Such growth will force extremely diffi- cult choices regarding how to pay for them.
Clearly, the political and social issues concerning benefits to older adults are quite complex. Driven by the eligibility of the first baby boomers for reduced Social Security benefits in 2008 and their eligibility for Medicare in 2011, the next decade will see the impact of previous inaction, and likely increased urgency to confront the issues. There are no easy solutions, and it will be essential to discuss all aspects of the problem. Let’s look more closely at Social Security and Medicare.
Social Security. Social Security had its beginnings in 1935 as an initiative by President Franklin Roosevelt to “frame a law which will give some measure of protec- tion to the average citizen and to his family against the loss of a job and against poverty-ridden old age.” Thus Social Security was originally intended to provide a supplement to savings and other means of financial support.
Two key things have changed since then. First, the proportion of people who reach age 65 has increased significantly. In 1940, about 54% of men and 61 % of women reached age 65 . Today, that’s changed to about 75 % of men and 85 % of women. Since 1940, men col- lect payments about 3 years longer, and women collect about 5 years longer. Both trends increase the cost of the program.
Second, revisions to the original law have changed Social Security so it now represents the primary source of financial support after retirement for most U.S. citi- zens, and the only source for many (Polivka, 2010). Since the 1970s, more workers have been included in employer-sponsored defined contribution plans such as 401 (k), 403 (b), 457 plans, and mutual funds, as well
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SUCCESSFUL AGING 411
as various types of individual retirement accounts (IRAs), but fewer defined benefit traditional pen- sion plans (Polivka, 2010). A key difference in these plans is defined contribution plans rely a great deal on employee participation (i.e., workers saving money for retirement) whereas traditional pension programs did not require employee participation as they pro- vided a monthly income for life paid completely by the company.
On the face of it, this inclusion of various retire- ment plans, especially savings options, may per- mit more future retirees to use Social Security as the supplemental financial source it was intended to be, thereby shifting retirement financial planning respon- sibility to the individual (Henrikson, 2007). But it may also be an increasing number of older adults rely on Social Security as their primary income source because of a lack of personal savings (Polivka, 2010).
The primary challenge facing Social Security is the aging of the baby boomers and the much smaller generation that follows (National Academy of Social Insurance, 2012). That’s why Nancy, the woman we met in the vignette, and other young adults are con- cerned. Because Social Security is funded by payroll taxes, the amount of money each worker must pay depends to a large extent on the ratio of the number of people paying Social Security taxes to the number of people collecting benefits. By 2030, this ratio will drop nearly in half; that is, by the time baby boomers have
largely retired, there will be nearly twice as many peo- ple collecting Social Security per worker paying into the system as there is today (Social Security Adminis- tration, 2012b).
Various plans have been proposed since the early 1970s to address this issue, and it has been a major agenda item in several presidential campaigns (e.g., 2004 and 2012). The 2012 election campaign focused attention on both Social Security and Medicare costs through proposals offered first by the Romney/Ryan ticket. Additionally, spending was a focus of the numerous debates on the federal budget in 2012 and 2013, especially in confronting the mandatory reduc- tions brought by the sequestration cuts that went into effect in 2013.
President Obama tackled the structure of Social Security in his FY2014 budget proposal by suggesting the calculation underlying the annual cost-of-living increases be redone to provide lower increases (Mont- gomery, 2913). Although the proposal would only lower increases by 0.3 % per year, the cumulative sav- ings would be substantial—amounting to about 20% of the projected 75 -year deficit. Such discussions and proposals will need to be considered and acted on before the baby boomers all reach maximum eligibility for the savings programs to have maximum effect.
How much of one’s wages are actually provided by Social Security depends on how much you made on aver- age during your employment career. Figure 14.3 shows
Figure 14.3 Social Security benefits compared to average annual wages. Source: Social Security Administra- tion. (2012). The 2012 Annual Report of the Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds. Retrieved from http://www.ssa.gov/oact /tr/2012/index.html. Table V.C7
A nn
ua l a
m o
un t
Low
34% 26%
55% 41%
$0
$20,000
$40,000
$19,400
$10,600
$23,300 $27,800
$43,000
$68,800
$106,800
$60,000
$80,000
$100,000
$120,000
Wage-earner who retires at age 65 in 2012
Earnings level
Medium High Maximum taxable
$17,500
Benefits Past wages
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this relation for a worker retiring in 2012 at age 65 who earned various wages on average while employed. As you can see, this ranges quite a bit depending on whether previous wages were low or the maximum taxable.
One point that confuses many people is the ben- efits received do not come from an “account” that reflects what you actually contributed over your employed career. Because Social Security is a revenue- in/payments-out model, people do not build up Social Security “savings.” Rather, the money they pay in taxes goes out as payments to those who are collecting ben- efits. So the payments current workers receive in the future will actually be from the taxes paid by workers in the labor force at that future time. That’s why the payee/recipient ratio matters—Social Security tax rates must inevitably go up or the benefits received must go down if there are fewer people paying to support an increasing number of recipients.
Over most of the life of Social Security, revenues were greater than payments. But that’s changed, as now payments exceed revenues. As a result, the inter- est from those saved revenues in the Social Security Trust Fund is now being spent to make up the differ- ence, and will keep the gap closed until 2021. If there are no changes in the law, and the moderate cost sce- nario occurs, by 2021 the Trust Fund itself will need to be liquidated by redeeming Treasury bonds. To get the money to redeem these bonds, the federal gov- ernment will need to increase taxes, reduce spend- ing in other government programs, or borrow money (thereby increasing the national debt). By 2033, all of the Trust Fund assets will be gone. Revenue from Social Security taxes would only cover about 75 % of the benefits promised.
Despite knowing the fiscal realities for decades, Congress has not yet taken the actions necessary to ensure the long-term financial stability of Social Secu- rity (Social Security Administration, 2012a,b).
Medicare . Over 52 million U.S. citizens depend on Medicare for their medical insurance (CMS.gov, 2012a). To be eligible, a person must meet one of the following criteria: be over age 65 , be disabled, or have permanent kidney failure. Medicare consists of three parts (CMS.gov, 2012b): Part A, that cov- ers inpatient hospital services, skilled nursing facili- ties, home health services, and hospice care; Part B,
covers the cost of physician services, outpatient hos- pital services, medical equipment and supplies, and other health services and supplies; and Part D, that provides some coverage for prescription medications. Expenses relating to most long-term care needs are funded by Medicaid, another major health care pro- gram funded by the U.S. government and aimed at people who are poor. Out-of-pocket expenses asso- ciated with co-payments and other charges are often paid by supplemental insurance policies, sometimes referred to as “Medigap” policies (Medicare.gov, 2013).
Like Social Security, Medicare is funded by a pay- roll tax. But unlike Social Security, where the income on which the tax is based has a cap, the tax support- ing Medicare is paid on all of one’s earnings. Still, the funding problems facing Medicare are arguably worse than those facing Social Security and are grounded in the aging of the baby-boom generation. In addition, Medicare costs have increased dramatically because of more rapid cost increases in health care. Expenditures will increase rapidly as the baby boomers increase the ranks of those covered.
Because of these rapid increases expected with the baby-boom generation, cost containment remains a major concern. The presidential elections of 2008 and 2012 included numerous debates about rapidly rising health care costs as a major economic problem facing the United States. Certainly, the debate around the Patient Protection and Affordable Care Act of 2010 heightened awareness of the issues.
Unlike Social Security, though, Medicare has been subjected to significant cuts in expenditures, typically through reduced payouts to health care providers. Pro- jected Medicare costs over the next 75 years are much lower than they would have been prior to the passage of the Patient Protection and Affordable Care Act in 2010 (Social Security Administration, 2012a).
Taken together, the challenges facing society con- cerning older adults’ financial security and health will continue to be major political issues throughout the first few decades of the 21 st century. There are no easy answers, but open discussion of the various arguments will be essential for creating the optimal solution. Pub- lic misperceptions and the tough choices that must be faced are discussed in more detail in the Current Con- troversies feature.
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SUCCESSFUL AGING 413
CURRENT CONTROVERSIES: WHAT TO DO ABOUT SOCIAL SECURITY AND MEDICARE As pointed out earlier in the chapter, the amount of money people collect in Social Security and Medicare is not directly connected to the amount they paid in taxes over their working careers. That’s a point many people misunderstand—they think they get out what they have put in. This misperception makes it difficult to make changes in the benefits structure (the cost) of these programs, especially Medicare.
The fact is in 2012, the average person collected about $ 3.00 in Medicare benefits for each dollar they paid in taxes on their earnings, premiums, and medi- cal co-payments. This imbalance (and misperception) is a major reason why restructuring the benefits or raising co-payments to control costs is so difficult to
do, and why the current benefit structure is unsustain- able for the baby boomers (Calmes, 2013).
On average, older Americans pay about 25 % of the cost of Medicare Part B and Part D through pre- miums, deductibles, and co-insurance (higher income people pay a larger share, up to 80 % ). General rev- enue in the national budget pays for the rest, and is why an increasing percentage of the federal budget is going to Medicare.
Similar analyses can be done for Social Security, but with a different outcome. Whereas nearly all Medicare recipients get much more out of the pro- gram than they paid in taxes, that’s not true for many people regarding Social Security.
Figure 14.4 shows comparisons between what a people earning various amounts of money on average during their employment careers and what they could expect to receive from Social Security and Medicare. Note, for example, a low-earning couple would receive
Figure 14.4 Average lifetime taxes paid and benefits received from Social Security and Medicare. © 2015 Cengage Learning
If you retire at age 65 in:
1960
$200,000
$400,000
$600,000
$800,000
$1,000,000
1960 1960
Taxes
Taxes
Taxes
Taxes
Taxes
SINGLE MEN Earning average wages of $44, 600 in 2012
Taxes
Social Security
Social Security
Social Security
Medicare
Medicare
Medicare Benefits
Benefits
Benefits
LOW-EARNING COUPLES Earning a total of $64,600 in 2012
HIGH-EARNING COUPLES Earning a total of $116,000 in 2012
Benefits
Benefits
WHAT YOU GET IN:
WHAT YOU PAY IN:
Benefits
1980 19801980 2030 2030 20302010 2010 20102020 2020 2020
adjusted for inflation. In 2012 dollars
Note: The figures for taxes paid are adjusted for inflation plus 2 percent, making the values comparable to what an individual might have earned had the money been invested in a savings account. The payroll tax calculations assume both the individual and employer contribution (most economists assume that individuals effectively bear the total expense through lower wages than employers might pay absent the tax). Figures for Medicare benefits are reduced to account for premiums that beneficiaries have paid. For example, a single male with average wages who retired at age 65 in 2010 would have paid about as much in Social Security taxes in his lifetime as he will receive in benefits. He receives more in Medicare benefits than he paid in taxes.
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the rate of aging (Aldwin & Gilmer, 2013). Promoting healthy lifestyles is important in all settings, including long-term care facilities (Thompson & Oliver, 2008).
Health Promotion and Quality of Life Even though changing unhealthy habits such as smok- ing and poor diet are difficult, chronic diseases such as arthritis make exercise challenging, and terminal disease makes it tough to see the benefits of chang- ing one’s habits, the fact remains such changes typi- cally increase functional capability. Current models of behavioral change are complex and include not only behavioral, but also motivational, cognitive, and social components (Aldwin & Gilmer, 2013). The two that are the focus of most research are the self-efficacy model that emphasizes the role of goal setting and personal beliefs in the degree one influences the outcome, and the self-regulation model, that focuses on the person’s motivation for change.
There is insufficient research on health promo- tion programs designed specifically for older adults (Aldwin & Gilmer, 2013). However, a few trends are apparent. First, although exercise is basic for good health, because older adults are more prone to injury, exercise programs for them need to take such issues into account and focus more on low impact aerobic approaches. Second, health education programs are effective in minimizing the effects of emotional stress. Third, health screening programs effectively identify- ing serious chronic disease that can limit the quality of life, and can be addressed through behavioral inter- ventions. Each of these areas within health promotion is most successful when ethnic differences are taken into account in designing the programs (Westmaas, Gil-Rivas, & Silver, 2011).
People’s state of health influences their quality of life , that is, their well-being and life satisfaction . Qual- ity of life includes interpersonal relationships and social
about what they paid in taxes in Social Security benefits, and much more from Medicare. What’s especially obvi- ous is everyone receives far more in Medicare benefits than they paid.
The challenge is the costs of Medicare must be controlled given the imminent arrival of most of the baby boomers. But explaining to those who are already receiving or are about to receive the benefit
is a daunting task. That’s why most proposals target individuals who are about 10 years away from receiving Medicare benefits.
The political debates around Social Security and Medicare will not end soon. What is clear, though, is the current financial model is unsustainable in the long run, and action, especially with respect to Medicare, is needed now.
Adult Development In Action How are demographics affecting social policy in the United States?
14.2 Health Issues And Quality Of Life LEARNING OBJECTIVES
What are the key issues in health promotion and quality of life?
What are the major strategies for maintaining and enhancing competence?
What are the primary considerations in designing health promotion and disease prevention programs?
What are the principal lifestyle factors that influence competence?
Jack heard about all the things available on the Web, and that he was missing a great deal. So, after he pur- chased his first home computer at age 68 , he began surf- ing. He never stopped. Now at age 73 , he’s a veteran with a wide array of bookmarked sites, especially those relat- ing to health issues. He also communicates by e-mail, and designed the community newsletter using his word-pro- cessing program. He recently created his Facebook page so he can keep up with his grandsons.
Jack is like many older adults—better educated and more technologically sophisticated than their pre- decessors. The coming demographic changes in the United States and the rest of the world in the aging baby boom generation present a challenge for improv- ing the kind of lives older adults live. For this reason, promoting healthy lifestyles is seen as one of the top health care priorities of the 21 st century (Lunenfeld, 2008). Remaining healthy is important for decelerating
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SUCCESSFUL AGING 415
support, physical and mental health, environmental comfort, and many psychological constructs such as locus of control, emotions, usefulness, personality, and meaning in life (Aldwin & Gilmer, 2013). Quality of life is usually divided into environmental, physical, social, and psychological domains of well-being. Personal eval- uation of these dimensions is critical to understanding how people view their situations. Although half of the people in Strawbridge, Wallhagen, and Cohen’s (2002) study did not meet certain objective criteria for success- ful aging, they nevertheless defined themselves as suc- cessful and as having a good quality of life.
In short, quality of life is a person’s subjective assessment or value judgment of his or her own life (Aldwin & Gilmer, 2013). This subjective judgment may or may not correspond to the evaluation of oth- ers. And even though self- and other-perceived quality of life may diminish in late life, it may not seem like a loss for the older person. An older woman who has difficulty walking may feel happy to simply be alive, whereas another who is in objective good health may feel useless. Quality of life is best studied from the point of view of the person.
Still, when the level of medical intervention increases as people grow more frail, medical profes- sionals must be concerned about the trade-off between extending life at all costs and the quality of that life, as discussed in chapter 13 (Michel, Newton, & Kirkwood, 2008). A longitudinal study in England showed clearly good health care makes a major difference in people’s quality of life and their average longevity (Steel, Melzer, & Richards (2013).
A Framework for Maintaining and Enhancing Competence
Although most older adults are not as computer liter- ate as Jack, the man introduced in the vignette, increas- ing numbers of older adults are discovering computers can be a major asset. Many take advantage of the grow- ing resources available on the Web, including sites dedicated specifically to older adults. E-mail and social networking enable people of all ages to stay in touch with friends and family, and the growing success of e-commerce makes it easier for people with limited time or mobility to purchase goods and services. Com- puters are already used in many health devices and likely to become ubiquitous in the home environment
of older adults in the relatively near future (Lesnoff- Caravaglia, 2010).
The use of technology is one way that technology can be used to enhance the competence of older adults. In this section, we consider the general topic of how to maintain and enhance competence through a vari- ety of interventions. How to grow old successfully is a topic of increasing concern in view of the demographic changes we considered earlier.
The life-span perspective we considered in Chap- ter 1 is an excellent starting point for understanding how to maintain and enhance people’s competence. In this perspective, the changes that occur with age result from multiple biological, psychological, sociocultural, and life-cycle forces. Mastering tasks of daily living and more complex tasks (such as personal finances) con- tributes to a person’s overall sense of competence even if the person has dementia (Mayo, 2008). How can this sense be optimized for successful aging?
The answer lies in applying three key adap- tive mechanisms for aging: selection, optimization, and compensation (SOC) (Baltes et al., 2006). This framework addresses what Bieman-Copland, Ryan, and Cassano (2002) call the “social facilitation of the nonuse of competence”: the phenomenon of older people intentionally or unintentionally failing to per- form up to their true level of ability because of social stereotypes that operate to limit what older adults are expected to do. Instead of behaving at their true abil- ity level, older adults behave in ways they believe typi- cal or characteristic of their age group (Lang, 2004).
OldOlder er r aduaduadultsltsts arara e ie incrnc easasingi ly l usiu ng ng tecechnnon logy to so staytay in toutouchchh witwitwith fh fh famiamia ly.ly.
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This phenomenon is the basis for the communication patterns we considered earlier in this chapter.
A key issue in the powerful role of stereotypes is to differentiate usual or typical aging from successful aging (Aldwin & Gilmer, 2013; Guralnik, 2008). Suc- cessful aging involves avoiding disease, being engaged with life, and maintaining high cognitive and physical functioning. Successful aging is subjective. It is reached when a person achieves his or her desired goals with dignity and as independently as possible.
The life-span perspective can be used to cre- ate a formal model for successful aging. Heckhausen, Wrosch, & Schulz (2010) developed a theory of life- span development based on motivation and control by applying core assumptions that recognize aging as a complex process that involves increasing specialization and is influenced by factors unrelated to age. The basic premises of successful aging include keeping a balance between the various gains and losses that occur over time and minimizing the influence of factors unrelated to aging. In short, these premises involve paying atten- tion to both internal and external factors impinging on the person. The antecedents include all the changes that happen to a person. The mechanisms in the model are the selection, optimization, and compensation pro- cesses that shape the course of development. Finally, the outcomes of the model denote that enhanced com- petence, quality of life, and future adaptation are the visible signs of successful aging.
Using the SOC model, enhanced by Heckhausen et al.’s (2010) notions of control and motivation, vari- ous types of interventions can be created to help people age successfully. In general, such interventions focus on the individual or on aspects of tasks and the physi- cal and social environment that emphasize compe- tence (Aldwin & Gilmer, 2013; Allaire & Willis, 2006; Bieman-Copland et al., 2002; Thornton, Paterson, & Yeung, 2013). When designing interventions aimed primarily at the person, it is important to understand the target person’s goals (rather than the goals of the researcher). For example, in teaching older adults how to use technology, it is essential to understand the kinds of concerns and fears older adults have and ensure the training program addresses them (Lesnoff- Caravaglia, 2010).
Performance on tests of everyday competence pre- dicts longer term outcomes (Allaire & Willis, 2006).
Careful monitoring of competence can be an early indicator of problems, and appropriate interventions should be undertaken as soon as possible.
Health Promotion and Disease Prevention By now you’re probably wondering how to promote successful aging. You may not be surprised to learn there is no set of steps or magic potion you can take to guarantee you will age optimally. But research using traditional methods as well as cutting-edge neuroim- aging is showing there are some steps you can take to quality of life and the odds of aging well (Aldwin & Gilmer, 2013; Guralnik, 2008; Reuter-Lorenz, 2013).
As you can see in Table 14.1 , most of the meth- ods are not complex. but they do capture the results of applying the model for maintaining and enhancing competence we examined at the beginning of the sec- tion. The key strategies are sound health habits; good habits of thought, including an optimistic outlook and interest in things; a social network; and sound eco- nomic habits.
These simple steps are difficult in practice, of course. Nevertheless, they will maximize the chances of aging successfully. Setting up this favorable outcome is important. Because of the demographic shifts in the population, health care costs for older adults in most developed countries are expected to skyrocket during the first half of the 21 st century, as we noted earlier. Minimizing this increase is key; following these prin- ciples can make that happen.
To support these changes, the U.S. Department of Health and Human Services created a national initia- tive to improve the health of all Americans through a coordinated and comprehensive emphasis on preven- tion. Updated every 10 years, the current version of
Table 14.1
Preventive strategies for maximizing successful aging Adopt a healthy lifestyle. Make it part of your daily routine.
Stay active cognitively. Keep an optimistic outlook and maintain your interest in things.
Maintain a social network and stay engaged with others.
Maintain good economic habits to avoid financial dependency.
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SUCCESSFUL AGING 417
this effort, the Healthy People 2020 initiative, sets tar- gets for a healthier population based on three broad goals: increase the length of healthy life, reduce health disparities among Americans, and achieve access to preventive services for all.
Although significant gains have been made in earlier versions of the initiative, they were not univer- sal. Many members of ethnic minority groups and the poor still have not seen significant improvements in their lives. With this in mind, there has been a shift from a focus that included only prevention to one that also includes optimum health practices.
The U.S. government allocates funds appropriated by the Older Americans Act through the Administra- tion on Aging (AoA) to provide programs specifically aimed at improving the health of older adults. These funds support a wide variety of programs, includ- ing health risk assessments and screenings, nutrition screening and education, physical fitness, health pro- motion programs on chronic disabling conditions, home injury control services, counseling regarding social services, and follow-up health services.
One goal of these low-cost programs is to address the lack of awareness many people have about their own chronic health problems; the AoA estimates half of those with diabetes mellitus, more than half with hypertension, and 70 % of those with high cholesterol levels are unaware they have serious conditions. Health promotion and disease prevention programs such as those sponsored by the AoA could reduce the cost of treating the diseases through earlier diagnosis and
better prevention education. Getting people to par- ticipate and then engage in healthy behavior, though, remains elusive.
Issues in Prevention. In Chapter 4 , we saw Verbrugge and Jette’s (1994) theoretical model offers a compre- hensive account of disability resulting from chronic conditions and provides much guidance for research. Another benefit of the model is it also provides insight into ways to intervene so disability can be prevented or its progress slowed. Prevention efforts can be imple- mented in many ways, from providing flu vaccines to furnishing transportation to cultural events so other- wise homebound people can enjoy these activities.
Traditionally, three types of prevention have been discussed that can be applied to aging: primary, sec- ondary, and tertiary (Haber, 2013). More recently, the concept of quaternary prevention has begun to be used (Scally, Imtiaz, Bethune, Young, Ward, Herzig et al., 2012). A brief summary is presented in Table 14.2 . Primary prevention is any intervention that prevents a disease or condition from occurring . Examples of pri- mary prevention include immunizing against illnesses such as polio and influenza or controlling risk factors such as serum cholesterol levels and cigarette smoking in healthy people.
Secondary prevention is instituted early after a con- dition has begun (but may not yet have been diagnosed) and before significant impairments have occurred . Examples of secondary intervention include can- cer and cardiovascular disease screening and routine
Table 14.2
Types of prevention interventions Type of Prevention Description Examples Primary Any intervention that prevents a disease or
condition from occurring Immunizations against diseases, healthy diet
Secondary Program instituted early after a condition has begun (but may not have been diagnosed) and before significant impairment has occurred
Cancer screening, other medical tests
Tertiary Efforts to avoid the development of complications or secondary chronic conditions, manage the panic associated with the primary chronic condition, and sustain life
Moving a bedridden person to avoid sores, getting medical intervention, getting a patient out of bed to improve mobility after surgery
Quaternary Effort specifically aimed at improving the functional capacities of people who have chronic conditions
Cognitive interventions for people with Alzheimer’s disease, rehabilitation programs after surgery
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medical testing for other conditions. These steps help reduce the severity of the condition and may even reduce mortality from it. In terms of the main pathway in Verbrugge and Jette’s (1994) model, secondary pre- vention occurs between pathology and impairments.
Tertiary prevention involves efforts to avoid the development of complications or secondary chronic con- ditions, manage the pain associated with the primary chronic condition, and sustain life through medical intervention . Some chronic conditions have a high risk of creating additional medical problems; for example, being bedridden as a result of a chronic disease often is associated with getting pneumonia. Tertiary preven- tion involves taking steps such as sitting the person up in bed to lower the risk of contracting additional diseases. In terms of the model, tertiary interventions are aimed at minimizing functional limitations and disability.
Tertiary prevention efforts do not usually focus on functioning but rather on avoiding additional medi- cal problems and sustaining life (Haber, 2013). Con- sequently, the notion of quaternary prevention has been developed to address functional issues (Scally et al., 2012). Quaternary prevention efforts are spe- cifically aimed at improving the functional capacities of people who have chronic conditions . Quaternary prevention strategies help health care professionals avoid unnecessary or excessive medical interventions, especially invasive ones. Some examples of quater- nary prevention are cognitive interventions to help people with Alzheimer’s disease remember things and occupational therapy to help people maintain their independence.
Although most efforts with older adults to date have focused on primary prevention, increasing atten- tion is being paid to secondary prevention through screening for early diagnosis of diseases such as can- cer and cardiovascular disease (see Chapters 2 and 3 ). Few systematic studies of the benefits and outcomes of tertiary and quaternary prevention efforts have been done with older adult participants, though. However, the number of such programs being conducted in local senior centers, health care facilities, and other settings is increasing steadily, with the focus of many of them on nutrition and exercise, as well as other behaviorally based strategies (Rippe, 2013).
The stakes are high. Because tertiary and quater- nary prevention programs are aimed at maintaining functional abilities and minimizing disability, they can be effective, lower-cost alternatives for addressing the needs of older adults with chronic conditions. Lifestyle factors are the basis for these behavioral approaches that are clearly gaining favor in the health care pro- fessional community (Rippe, 2013). Comprehensive health care reform will likely adopt many more of these approaches; especially given they are grounded in research, making them evidence-based. Let’s take a closer look.
Lifestyle Factors Most attention in health promotion and disease pre- vention programs is on tackling a handful of behaviors that have tremendous payoff, such as keeping fit and eating properly. In turn, these programs educate adults about good health care practices and identify condi- tions such as hypertension, high cholesterol levels, and elevated blood sugar levels, which, if left untreated, can cause atherosclerosis, heart disease, strokes, diabetes mellitus, and other serious conditions.
Exercise. Since the ancient Greeks, physicians and researchers have known exercise significantly slows the aging process. Indeed, evidence suggests a program of regular exercise, in conjunction with a healthy life- style, can slow the physiological aging process (Aldwin & Gilmer, 2013). Being sedentary is absolutely hazard- ous to your health.
Adults benefit from aerobic exercise , that places moderate stress on the heart by maintaining a pulse rate between 60 % and 90 % of the person’s maximum heart rate . You can calculate your maximum heart rate by subtracting your age from 220 . Thus, if you are 40 years old, your target range would be 108 – 162 beats per minute. The minimum time necessary for aerobic exercise to be of benefit depends on its intensity; at low heart rates, sessions may need to last an hour, whereas at high heart rates, 15 minutes may suffice. Examples of aerobic exercise include jogging, step aerobics, swimming, and cross-country skiing.
What happens when a person exercises aerobi- cally (besides becoming tired and sweaty)? Physiolog- ically, adults of all ages show improved cardiovascular functioning and maximum oxygen consumption;
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SUCCESSFUL AGING 419
lower blood pressure; and better strength, endurance, flexibility, and coordination (Mayo Clinic, 2011). Psy- chologically, people who exercise aerobically report lower levels of stress, better moods, and better cogni- tive functioning.
The best way to gain the benefits of aerobic exer- cise is to maintain physical fitness throughout the life span, beginning at least in middle age. The benefits of various forms of exercise are numerous, and include lowering the risk of cardiovascular disease, osteoporo- sis (if the exercise is weight bearing), and a host of other conditions. The Mayo Clinic’s Fitness Center provides an excellent place to start. In planning an exercise pro- gram, three points should be remembered. First, check with a physician before beginning an aerobic exercise program. Second, bear in mind that moderation is important. Third, just because you intend to exercise doesn’t mean you will; you must take the necessary steps to turn your intention into action (Schwarzer, 2008). If you do, and stick with it, you may feel much younger (Joyner & Barnes, 2013).
Without question, regular exercise is one of the two most important behaviors you can do to pro- mote healthy living and good aging (not smoking is the other). In addition to the wide variety of posi- tive effects on health (e.g., lower risk of cardiovas- cular disease, diabetes, hypertension), there is also substantial evidence exercise is also connected to less cortical atrophy, better brain function, and enhanced cognitive performance (Erickson, Gildengers, & Butters, 2013). Specifically, exercise has a positive effect on the prefrontal and hippocampal areas of the brain, and as we have seen, is closely associated with
memory and other cognitive functions. Whether exercise can delay or prevent diseases associated with these brain structures, such as Alzheimer’s dis- ease, remains to be seen. But the evidence to date points to reason to promote exercise as a way to a healthy, better functioning brain in later life. A better functioning brain may well be related to the mood improvements seen as another positive benefit of exercise, as shown in Figure 14.5 .
In summary, if you want to maximize the odds of aging well, exercise. Guidelines state about 150 minutes of moderate aerobic exercise weekly with additional whole-body strength training and balance work is sufficient to produce positive effects (Batt, Tanji, & Börjesson, 2013). When you are done your routine for the day, watch what you eat, as discussed next.
ExeExeExercircise se is is a ma ma majoajoajor wr wr way ayay tot hele p p dp delaayy oy or pr pr revreventent chchhronic disdisseaseasease ae and nd proproromotmotmote ae ae hehealtaltthy hy h llatlate le life.
Figure 14.5 A schematic representation of the general path by which cognitive function and mood are improved by physical activity, it could be hypothesized that improvements in cognitive function mediate the improvements in mood or that improvements in mood mediate some of the improvements in cognitive function. The dotted lines represent these hypothesized paths. Source: Erickson, K. I., Gildengers, A. G., & Butters, M. A. (2013). Physical activity and brain plasticity in late adulthood. Dialogues in Clinical Neuroscience, 15, 99–108. Open source, retrieved from http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3622473/. Image retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622473/figure /DialoguesClinNeurosci-15-99-g001/.
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420 CHAPTER 14
Nutrition . How many times did your parents tell you to eat your vegetables? Or perhaps they said, “You are what you eat.” Most people have disagreements with parents about food while growing up, but as adults they realize those lima beans and other despised foods their parents urged them to eat really are healthy.
Experts agree nutrition directly affects one’s men- tal, emotional, and physical functioning (Hammar & Östgren, 2013). Diet has been linked to cancer, car- diovascular disease, diabetes, anemia, and digestive disorders. Nutritional requirements and eating habits change across the life span. This change is due mainly to differences in, or how much energy the body needs, termed metabolism . Body metabolism and the diges- tive process slow down with age (Janssen, 2005).
The U.S. Department of Agriculture publishes dietary guidelines based on current research. In its Dietary Guidelines for Americans 2010 (U.S. Depart- ment of Agriculture, 2010), the USDA recommends we eat a variety of nutrient-dense foods and beverages across the basic food groups. The general guidelines for
older adults can be seen in Figure 14.6 . These guide- lines are based on the general guidelines for younger and middle-aged adults. As you can see, the USDA approaches nutrition from the perspective of ensur- ing people eat a healthy plate of food at each meal, and the contents of that plate be appropriately balanced. Most important, we should choose foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol. And we need to keep our tar- get calorie intake in mind.
Of course, most people do not eat perfectly all the time. Did you ever worry as you were eating a triple- dip cone of premium ice cream you really should be eating fat-free frozen yogurt instead? If so, you are among the people who have taken to heart (literally) the link between diet and cardiovascular disease. The American Heart Association (2013) makes it clear foods high in saturated fat (such as our beloved ice cream) should be replaced with foods low in fat (such as fat-free frozen yogurt). Check out their website for the latest in advice on eating a heart-healthy diet.
Figure 14.6 Dietary guidelines for older adults Copyright 2011 Tufts University. For details about MyPlate for Older Adults, please see http:// www.nutrition.tufts.edu/ documents/MyPlateforOlder Adults.pdf
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SUCCESSFUL AGING 421
The main goal of these recommendations is to lower your level of cholesterol because high cholesterol is one risk factor for cardiovascular disease. There is an important difference between two different types of cholesterol, that are defined by their effect on blood flow. Lipoproteins are fatty chemicals attached to pro- teins carried in the blood. Low-density lipoproteins (LDLs) cause fatty deposits to accumulate in arteries, impeding blood flow, whereas high-density lipopro- teins (HDLs) help keep arteries clear and break down LDLs . It is not so much the overall cholesterol num- ber but the ratio of LDLs to HDLs that matters most in cholesterol screening. High levels of LDLs are a risk factor in cardiovascular disease, and high levels of HDLs are considered a protective factor. Reduc- ing LDL levels is effective in diminishing the risk of cardiovascular disease in adults of all ages; in healthy adults, a high level of LDL (over 160 mg / dL ) is associ- ated with higher risk for cardiovascular disease (Mayo Clinic, 2012c). In contrast, higher levels of HDL are good (in healthy adults, levels at least above 40 mg / dL for men and 50 mg / dL for women). LDL levels can be lowered and HDL levels can be raised through various interventions such as exercise and a high-fiber diet. Weight control is also an important component.
If diet and exercise are not effective in lowering cholesterol, numerous medications exist for treating cholesterol problems. The most popular of these drugs are from a family of medications called statins (e.g., Lipitor, Crestor). These medications lower LDL and
moderately increase HDL. Because of potential side effects on liver functioning, patients taking cholesterol- lowering medications should be monitored on a regular basis.
Obesity is a growing health problem related to diet. One good way to assess your own status is to com- pute your body mass index. Body mass index (BMI) is a ratio of body weight and height and is related to total body fat . You can compute BMI as follows:
BMI = w / h 2
where w = weight in kilograms (or weight in pounds divided by 2.2 ), and h = height in meters (or inches divided by 39.37 ).
The Centers for Disease Control and Prevention (2011) defines healthy weight as having a BMI of less than 25 . However, this calculation may overestimate body fat in muscular people and underestimate body fat in those who appear of normal weight but have little muscle mass.
BMI is related to the risk of serious medical condi- tions and mortality: the higher one’s BMI, the higher one’s risk (Centers for Disease Control and Prevention, 2011). Figure 14.7 shows the increased risk for several diseases and mortality associated with increased BMI. Based on these estimates, you may want to lower your BMI if it’s above 25 . But be careful—lowering your BMI too much may not be healthy either. Very low BMIs may indicate malnutrition, which is also related to increased mortality.
Disease risk * Relative to normal weight and waist circumference
BMI (Kg/m2)
Obesity class
Men 102 cm (40 in) or less Women 88 cm (35 in) or less
Men > 102 cm (40 in) Women > 88 cm (35 in)
Underweight <18.5 – – Normal 18.5–24.9 – –
Overweight 25.0–29.9 Increased High
Obesity 30.0–34.9 I High High
35.9–39.9 II Very high Very high
Extreme obesity 40.0 III Extremely high Extremely high
Figure 14.7 Classification of overweight and obesity by BMI, waist circumference, and associate disease risks. Source: Centers for Disease Control and prevention (2007b).
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422 CHAPTER 14
Approaches to Successful Aging Everyone hopes his or her later years are ones filled with good health, continued high cognitive and physi- cal competence, and engagement with life. As common sense as this view seems, it did not significantly influ- ence research on aging until the latter part of the twen- tieth century. Rowe and Kahn (1998) changed that. They considered these views to be the foundation on which successful aging is built:
The absence of disease and disability makes it easier to maintain mental and physical func- tion. Maintenance of mental and physical function in turn enables (but does not guar- antee) active engagement with life. It is the combination of all three—avoidance of dis- ease and disability, maintenance of cognitive and physical function, and sustained engage- ment with life—that represents the concept of successful aging most fully ( 39 ) .
Research participants agree. An extensive study of people’s own definitions of successful aging conducted in Canada showed substantial agreement between participants’ definitions and Rowe and Kahn’s three dimensions (Tate, Lah, & Cuddy, 2003).
This three-part view of successful aging has become the central theoretical paradigm in gerontol- ogy and geriatrics. Numerous calls for a rethinking of research, clinical and application approaches to aging have been made that are grounded in this work (e.g., Aldwin & Gilmer, 2013; Jeste & Palmer, 2013; Reuter- Lorenz, 2013).
Vaillant (2002) proposed a similar model of suc- cessful aging that has six criteria rather than three. He proposes three criteria related to health:
No physical disability at age 75 as rated by a physician
Good subjective physical health (i.e., no problems with instrumental activities of daily living)
Length of undisabled life
Vaillant’s other three criteria relate to social engage- ment and productive activity:
Good mental health
DISCOVERING DEVELOPMENT: WHAT IS SUCCESSFUL AGING? What does it mean to age successfully? Take some time to think about this question for yourself. Develop a thorough list of everything it would take for you to say you will have aged successfully when the time comes. Then ask this question to several people of different ages and backgrounds. Compare their answers. Do the criteria differ as a function of age or background characteristics? Discuss your find- ings with others in your class to see whether your results were typical.
14.3 Successful Aging LEARNING OBJECTIVES
What is successful aging? What theoretical models have been proposed?
What criticisms have been raised about the successful aging framework?
Marie Chen just celebrated her 100 th birthday. During the daylong festivities, many people asked her whether she believed she had a good life and had, in a sense, aged successfully. She answered everyone the same way, telling them she had her health, enough money to live on, and her family. What more could she want?
Marie gives every sign of having aged well. She’s 100 years old, with a loving family, good enough health to live in the community, and enough income to pay her bills. But is there more to it than that? Before you read what researchers have to say about aging success- fully, complete the exercise in the Discovering Devel- opment feature.
Adult Development in Action How could the information about exercise and nutri- tion in this section be combined with the health information in Chapters 3 and 4 to create an educa- tion program for adults?
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SUCCESSFUL AGING 423
Objective social support Self-rated life satisfaction in eight domains: mar-
riage, income-producing work, children, friendships and social contacts, hobbies, community service activities, religion, and recreation/sports
What is important in Vaillant’s model is not only what predicts long life but also what does not. Inter- estingly, having had long-lived ancestors was impor- tant only up to age 60 but not beyond. Stress-related diseases before age 50 were not predictive. Childhood factors that were important predictors of health at midlife did not predict health in late life. Thus Vail- lant’s research emphasizes late life has many unique aspects and may not relate to variables that predict health at earlier points in life.
A related view of successful aging is one we encountered several times throughout the book: the selection, optimization, and compensation (SOC) model (Baltes et al., 2006). Recall in this model selec- tion refers to developing and choosing goals, optimiza- tion to the application and refinement of goal-relevant means or actions, and compensation to substitution of means when previous ones are no longer available.
The SOC model can be applied to the proactive strategies of life management. From this perspective, it is adaptive (i.e., a sign of successful aging) to set clear goals, to acquire and invest means into pursuing these goals, and persist despite setbacks or losses. So the point here, in contrast to a coping strategy, that would emphasize a more passive approach, is taking positive action to find substitute ways of doing things is adap- tive (Freund & Baltes, 2002).
Critiques of the Successful Aging Framework
Taking a broad view to defining successful aging per- mits researchers to establish what is associated with it. But there’s a fundamental problem. Unlike the case with diseases, in which labels have specific meanings, the term “successful aging” lack that consensus, mak- ing it difficult to specify exactly what the criteria are for achieving it (Cosco, Stephan, & Brayne, 2013). The lack of consensus makes it hard to know whether the outcome is something specific, or simply the result of a certain confluence of other factors.
Studies indicate aging successfully is more likely when people have higher levels of education, house- hold income, and personal income. We saw earlier that income is related to health, because of better access to health care and greater knowledge of healthy behaviors and ability to engage in them. Additionally, unfavor- able conditions in childhood lower the odds of people aging successfully according to research in Europe (Brandt, Deindl, & Hank, 2012). This is sobering news given the numbers of children globally that live in pov- erty; that experience follows them for life.
The increased emphasis on successful aging regardless of definition raises important questions about the quality of life for older adults. Research- ers have not focused much attention on the issue of whether one can outlive one’s expected longevity, that is, how long you think you will live, and if so, what psy- chological effects that can have. If you think you will not live past age 75 , perhaps because no one in your family ever has, you may map out your life based on this assumption. But what do you do when you cele- brate your 76 th birthday? The birthday wasn’t planned, and you may feel confused as to what you should be doing with yourself. Do you feel fortunate you have more life to live? Or not?
Rowe and Kahn’s view of successful aging, along with similar models, make several key assumptions that may not be universally true: (a) people have the resources to live a healthy life, (b) access to health care, (c) live in a safe environment, (d) have life experi- ences that support individual decision making, and so forth (de Lange, 2013; Holstein & Minkler, 2003). Not
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424 CHAPTER 14
all older adults’ lives meet these assumptions (Liang & Luo, 2012). Poverty, widowhood, and differential social expectations based on gender influence whether a person will be able to exert individual control and decisions over health (Cruikshank, 2013).
There is another, more serious concern with Rowe and Kahn’s model. By equating health and successful aging, they imply older people who have health prob- lems have not aged successfully (Holstein & Minkler, 2003; Liang & Luo, 2012). By suggesting people who have disabilities or health limitations signify failure, or at best “usual” aging, the message that only the fit and vigorous are successful is a negative one. It can also inad- vertently reinforce the antiaging stereotype for physical beauty as well as a stereotype for the “active older adult.”
Holstein and Minkler (2003) point out we should return to an ancient question: What is the good life— for the whole of life—and what does it take to live a good old age? When she was in her late 60s, the late poet May Sarton (1997) wrote this about the immi- nence of death: “[P]reparing to die we shed our leaves, without regret, so that the essential person may be alive and well at the end” ( 230 ) .
Sarton’s view may remind you of another, related perspective. Erikson (1982) talked about successful aging as ego integrity, a point made by some research- ers as well (Chang et al., 2008). Successful aging may be the ability to pull one’s life together from many perspec- tives into a coherent whole and to be satisfied with it. From this perspective, successful aging is assessed more from the older adult’s vantage point than from any other (Bowling, 2007). In this sense, older adults may say they are aging successfully while others, especially those who adopt a medical model, would not say that about them. But who is to say which perspective is “correct”?
Perhaps the middle ground is to aim for harmonious aging (Liang & Luo, 2012) that aims for balance, not uni- formity. In this view, “good aging” is grounded in one’s culture, and reflects the fact there is no one right way to age well. And it just may come down to what you think about your own situation. If you are happy with the way your life is, then perhaps that’s all that’s necessary.
Epilogue In this book, you have seen a snapshot of what adult development and aging are like today. You learned about their complexities, myths, and realities. But more
than anything else, you have seen what we really know about the pioneers who blazed the trail ahead of us.
In a short time, it will be your turn to lead the jour- ney. The decisions you make will have an enormous impact on those who will be old: your parents, grand- parents, and the people who taught you. The decisions will not be easy ones, but you have an advantage that the pioneers did not. You have the collected knowledge of gerontologists to help. With a continued concerted effort, you will be able to address the problems and meet the challenges that lie ahead. Then, when you yourself are old, you will be able to look back on your life and say, “I lived long—and I prospered.”
Summary 14.1 Demographic Trends and Social Policy
What key demographic changes will occur by 2030? The rapid increase in the number of older adults
between now and 2030 means social policy must take the aging of the population into account. Changing demographics will affect every aspect of life in the United States and in most other countries, including health care and all social service programs.
What are the challenges facing Social Security and Medicare?
Although designed as an income supplement, Social Security has become the primary source of retirement income for most U.S. citizens. The aging of the baby boom generation will place consider- able stress on the financing of the system.
Medicare is the principal health insurance program for adults in the United States over age 65 . Cost con- tainment is a major concern, resulting in emphases on program redesign for long-term sustainability.
14.2 Health Issues and Quality of Life
What are the key issues in health promotion and quality of life?
Health promotion will become an increasingly important aspect of health care for older adults. Two models of behavioral change currently drive research: the self-efficacy model and the self- regulation model.
Quality of life, a person’s well-being and life satis- faction is best studied from the perspective of the individual.
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SUCCESSFUL AGING 425
What are the major strategies for maintaining and enhancing competence?
A useful framework for enhancing and maintain- ing competence is the selection, optimization, and compensation (SOC) model.
The life-span approach provides a guide for design- ing competency-enhancing interventions.
What are the primary considerations in designing health promotion and disease prevention programs?
Effective strategies for health promotion and dis- ease prevention are adopting a healthy lifestyle, staying active cognitively, maintaining a social net- work, and preserving good economic habits.
Four levels of prevention are: primary (preventing a disease or condition from occurring), secondary (intervening after a condition has occurred but before it causes impairment), tertiary (avoiding the development of complications), and quaternary (improving functional capacities in people with chronic conditions).
What are the principal lifestyle factors that influence competence?
Maintaining a good exercise program and get- ting good nutrition are essential for delaying or preventing many negative aspects of physiological aging, especially chronic diseases.
14.3 Successful Aging
What is successful aging? What theoretical models have been proposed?
Successful aging is a commonly used, but ill-defined framework. Models of successful aging include this notion: Rowe and Kahn’s, Vaillant’s, and variations on the selection, optimization, and compensation (SOC) model.
What criticisms have been raised about the successful aging framework?
The successful aging framework has been criticized because of its reliance on good health, adequate income, and other variables that heavily influence outcomes in late life. Advocating a balance in one’s life may be a better approach.
Review Questions 14.1 Demographic Trends and Social Policy
What will the population of the United States look like in 2030?
What social policy impact will these changes have? What pressures are there on Social Security and
Medicare?
14.2 Health Issues and Quality of Life Why is health promotion likely to become increas-
ingly important? What is meant by the term quality of life? What theoretical framework provides the best
approach for enhancing competency? What are four effective strategies for health pro-
motion and disease prevention? What are the four types of prevention strategies? Why are exercise and nutrition important for
health promotion and disease prevention?
14.3 Successful Aging What is successful aging, and how is it best studied? What are the similarities and differences among
the Rowe and Kahn, Vaillant, and SOC models? What criticisms have been raised regarding the suc-
cessful aging framework?
INTEGRATING CONCEPTS IN DEVELOPMENT Suppose you were brought in as a consultant on
aging policy issues to your national government. Based on the demographic information in Chapter 1 and this chapter, what recommendations would you make?
What trends in health care do you think will emerge based on information in this chapter and in Chapters 3 , 4 , and 10 ?
How do you think older adults will define success- ful aging in the future?
KEY TERMS aerobic exercise Exercise that places moderate stress on the heart by maintaining a pulse rate between 60 % and 90 % of the person’s maximum heart rate.
body mass index (BMI) A ratio of body weight and height that is related to total body fat.
dependency ratio The ratio of the number of people under age 15 and over age 64 in a country to the num- ber of people between 15 and 64 .
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426 CHAPTER 14
high-density lipoproteins (HDLs) Help keep arteries clear and break down LDLs.
low-density lipoproteins (LDLs) Cause fatty deposits to accumulate in arteries, impeding blood flow.
metabolism How much energy the body needs.
primary prevention Any intervention that prevents a disease or condition from occurring.
quality of life A person’s well-being and life satisfaction.
quaternary prevention Efforts specifically aimed at improving the functional capacities of people who have chronic conditions.
secondary prevention Instituted early after a condi- tion has begun (but may not yet have been diagnosed) and before significant impairments have occurred.
tertiary prevention Involves efforts to avoid the devel- opment of complications or secondary chronic condi- tions, manage the pain associated with the primary chronic condition, and sustain life through medical intervention.
RESOURCES Access quizzes, glossaries, flashcards, and more at www.cengagebrain.com.
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NAME INDEX I-1
NAME INDEX Abdollahi, M., 66 Abelson, J. M., 276 Aberson, C. L., 312 Abraham, A., 211 Accardi, G., 96 Adams, C., 240 Adams, J., 323 Adams, R. B., Jr., 226 Adams, R. G., 312 Addis, D. R., 44, 169 Adler, L. L., 316 Adler, N. E., 60 Adler-Baeder, F., 328 Agrawal, Y., 71 Agrigoroaei, S., 173 Ai, A. L., 268, 269 Aisen, P. S., 293 Ajrouch, K., 8 Åkerstedt, A. M., 264 Alam, S., 36 Albert, M. A., 293 Albert, M. S., 293 Alcalay, L., 316 Aldwin, C. M., 62, 63, 67, 68,
74, 129 Alegría, M., 283 Alexander, G. E., 40 Allaire, J. C., 134, 208, 239 Allard, M., 196 Allemand, M., 250 Allen, J. E., 142 Allen, R. S., 151 Allen-Burge, R., 151 Allensworth, M., 316 Alley, J. L., 336 Allik, J., 316 Almeida, J., 331 Almendarez, B. L., 144 Alvarez-Buylla, A., 50 Alves, G., 300 Amato, P. R., 327 Ambati, J., 70 Amieva, H., 196 Amoyal, N., 197 An, Y., 294 Anand, A., 287 Andel, R., 68 Andersen, G. J., 69 Andersen, S. L., 117 Anderson, E. R., 331 Anderson, R. A., 145 Anderson, V. D., 330 Anderson, W. A., 313 Ando, S., 39 Andreoletti, C., 197 Andresen, E., 99, 283 Andrew, F., 332
Andrew, M., 113 Andrews-Hanna, J. R., 48 Aneshensel, C. S., 298 Angeles, L., 329 Ankudowich, E., 171 Antenucci, V., 175, 297 Anticevic, A., 205 Antonucci, T. C., 278 Apperly, I. A., 162 Araki, M., 95 Araujo, A. B., 84 Ardelt, M., 211, 212 Arnett, J. J., 14, 259, 311 Arnold, M., 115 Arnold, S. E., 196, 197 Artistico, D., 209 Ascensão, A., 171 Aslan, A., 161 Asoodeh, M. H., 322 Asp, E., 229 Assaf, Y., 177 Atzori, M., 178 Aubry, M., 179 Ault, L., 316 Auman, C., 172 Austers, I., 316 Austin, J. T., 206 Aziz, T., 316
Babakchanian, S., 300 Bach, P. B., 82 Bachmann, K. A., 114 Backhouse, J., 337 Bäckman, L., 39, 50, 160, 165, 175 Baddeley, A., 163, 285 Bade, M. K., 105 Baek, J., 325 Bagwell, C. L., 312 Bailey, H., 166 Baillargeon, A., 178 Baker, L. A., 336 Balfour, J. L., 120 Balistreri, C. R., 96 Ball, K., 198 Ballotta, E., 178 Baltes, B. B., 233 Baltes, P. B., 4, 5, 11, 16, 50, 100,
162, 186, 188, 189, 195, 211, 218, 233
Band, G. P. H., 162 Bandettini, P. A., 51 Banerjee, A. V., 8 Baracchini, C., 178 Barberger-Gateau, P., 52 Barch, D. M., 205 Bardach, S. H., 268 Barez, S., 70
Bargh, J. A., 220 Barich, M. T., 265, 266, 267 Barja, G., 95 Barnes, L. L., 196 Barnett, A. E., 333 Baron, G., 82 Barrett, B. J., 318 Bar-Tal, Y., 234, 235 Bartels, S. J., 303 Bartke, A., 59 Barzilai, N., 59 Basak, C., 198 Bastida, E., 268 Bastos, A., 327 Battista, R. N., 109 Batty, G. D., 195 Bauman, U., 258 Baumeister, R.F., 268 Bäuml, K.-H. T., 161 Beach, C. M., 283 Beach, S. R. H., 323, 326, 327 Bearse, M. A., Jr., 70 Beason-Held, L. L., 294 Beatty, C., 230, 231 Beaulieu, E., 144 Beck, A. T., 284, 285, 287 Beckes, L., 312 Beckett, L. A., 293 Belzares, E., 82 Bencosme, A., 82 Benedek, M., 195 Benight, C. C., 281 Benjamin, A. S., 171 Benjamin, E. J., 77 Benjamins, M. R., 100 Bennett, D. A., 197 Bennett, K. M., 324, 328 Berch, D. B., 198 Berg, C. A., 187, 208, 209, 324 Berger, R. G., 60 Berglund, P., 276, 277 Bergman-Evans, B., 152 Bergner, S., 195 Bergsma, A., 212 Berk, M., 286 Berlin, L. J., 330 Bernabei, R., 60 Bernier, J., 121 Berry, E. M., 234 Berry, J. D., 77 Berry, J. M., 173 Bertolino, M., 218 Besedeš, T., 206 Beudt, S., 211 Beversdorf, D., 103 Beyer, M. K., 300 Biblarz, T. J., 332
Bienias, J. L., 197 Bierman, A., 236 Biesele, M., 16 Bigby, C., 134 Birditt, K. S., 240 Birren, J. E., 13, 263, 276 Bishara, A. J., 171 Bishop, A. J., 280 Bitnes, J., 75 Black, D. R., 121 Blackburn, E., 60 Blacker, D., 295 Blancato, R. B., 338 Blanchard-Fields, F., 34, 45, 204,
209, 217, 222, 223, 224, 228, 230, 231, 232, 233, 234
Blancquaert, I., 109 Blasko, I., 290 Blatteis, C. M., 85 Blatt-Eisengart, I., 173 Blazer, D. G., 99 Bleich, S., 290 Blieszner, R., 50, 311, 312, 313 Blom, M. M., 298 Blomstedt, Y., 99 Blossfeld, H.-P., 314 Blümel, J. E., 82 Boccardi, V., 95 Bodenmann, G., 324, 327 Bolkan, C., 247 Bond, J., 119 Bontempo, D., 196 Bookheimer, S. Y., 300 Boom, J., 22 Boot, W. R., 198 Booth, A. L., 100 Borden, W. B., 77 Boron, J. B., 197 Bosma, H., 196 Bosman, E. A., 210 Bosmans, J. E., 298 Boswell, G., 268 Bottirolli, S., 222, 236 Botwinick, J., 186 Bourgeois, M. S., 176 Bova, M., 96 Bowen, C. E., 250, 332 Bowman, G. L., 52 Boyle, P. J., 328 Boywitt, C. D., 170 Braam, A. W., 99 Bradbury, T. N., 322 Bradford, A., 291 Brady, C. B., 197 Brady-Smith, C., 330 Brady-Van den Bos, M., 164 Brancucci, A., 194
44918_name index_ptg01_hr_I-1-I-8.indd I-144918_name index_ptg01_hr_I-1-I-8.indd I-1 28/12/13 9:08 AM28/12/13 9:08 AM
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I-2 NAME INDEX
Brandburg, G. L., 145 Brandtstädter, J., 218, 235, 236, 237 Braun, S. D., 332 Bressette, M., 130 Brett, C. E., 100 Bribiescas, R. G., 83 Brigman, S., 222 Brissett-Chapman, S., 330 Brissette, I., 312 Brodaty, H., 293 Bromell, L., 312 Bronnick, K. S., 300 Bronson-Castain, K. W., 70 Brooks- Gunn, J., 330 Brouwer, A., 136 Brown, A. S., 165 Bruno, D., 164 Brush, J., 175, 297 Bu, G., 294 Buchanan, T., 314, 315 Buffa, S., 96 Bugental, D., 148 Bugg, J. M., 168 Buhl, H., 332 Bulati, M., 96 Bull, M. J., 139 Bullock, K., 337 Burge, S. W., 140 Burgio, K. L., 113 Burgio, L. D., 296 Burnette, D., 336 Burnstein, E., 228 Burton-Chase, A., 222 Buvens, C., 164
Caballero, D., 218 Cabeza, R., 35, 36, 41, 42, 43, 48 Cacioppo, J. T., 265 Cadigan, R. O., 146 Cagney, K. A., 312 Cahill, E., 334 Cairney, J., 106 Calandra, C., 278 Calle, A., 82 Calvani, R., 60 Cameron, R. E., 337 Camfield, D., 198 Camp, C. J., 15, 174, 175, 176, 297 Campbell, A., 103 Campbell, J., 103 Candore, G., 96 Cansino, S., 170 Cantor, N., 253 Capaldi, D. M., 326 Capizzano, A. A., 178 Cappeliez, P., 324 Caramagno, J., 278 Caraviello, R., 100, 128 Carlo, G., 331 Caron, C. D., 144 Carr, D., 313, 328 Carrillo, M. C., 293 Carroll, N., 100 Carstensen, L. L., 45, 170, 207, 217,
233, 234, 237, 265, 313 Carter, L., 71 Carvalho, J. O., 264 Carver, C., 312
Casañas i Comabella, C., 279 Casey, V. A., 169 Caspi, A., 250 Cassell, M. D., 178 Cassidy, E., 147 Castel, A. D., 172, 173 Castellano, C. A., 52 Catheline, G., 196 Cavallini, E., 222, 236 Cavanaugh, J. C., 20, 60, 105, 172,
173, 322, 334 Cengiz, M., 301 Cervone, D., 209 Chan, M. F., 296 Chan, S. W-C., 269 Chandra, A., 320 Chang, H. Y., 96 Chang, T.-S., 313 Chapman, B., 322 Charles, S. T., 265, 313 Charman, W. N., 69, 70 Charness, N., 210 Charpentier, M., 240 Chasteen, A. L., 268 Chatfield, M. D., 180 Chatters, L. M., 269 Cheadle, J., 327 Chedraui, P., 82 Chee, F. Y. T., 148 Chen, F., 132 Chen, J., 99 Chen, Y., 229 Cheng, C., 203 Cherlin, A. J., 326 Chern, H.-L., 119 Cherry, K. E., 161, 222 Chertkow, H., 293 Chi, M. T. H., 209 Chin, L., 131 Chiodo, L. M., 264 Chiou, Y.-E., 119 Chiu, H. F. K., 293 Choi, B.-Y., 279 Chong, S., 293 Chou, S.-C., 147 Chou, Y.-Y., 300 Choudhary, S., 62 Chouinard-Watkins, R., 52 Choula, R., 333 Christ-Crain, M., 83 Christensen, A., 326 Christodoulou, M., 196 Cicero, C., 100, 128 Cinnirella, M., 12 Cirelli, C., 86 Clare, L., 303 Clark, M., 143 Clarke, L. H., 67 Clelland, C., 290 Clevinger, A. M., 170 Clifford, D., 332 Coan, J. A., 312 Codding, R., 175 Codispoti, K.-E. T., 294 Coehlo, D. P., 324 Cohen, D., 325, 334 Cohen, M. D., 268 Cohen, O., 324
Cohen, S., 103, 106 Cohen- Mansfield, J., 171 Colcombe, S., 171, 172 Cole, C. A., 206, 229 Coleman, K. A., 169 Collerton, J., 119 Collins, H. M., 161 Collins, K., 48 Collins, W. A., 314 Coman, A., 240 Connidis, I. A., 324 Connolly, A., 151 Conradi, L., 317 Constantinidou, F., 196 Conway, M. A., 170 Cooper, A. M., 197 Cooper, C., 318 Corkin, S., 43, 234 Corley, J., 100 Corpuz, R., 148 Cosh, S. M., 283 Costa, P. T., 249, 250, 252 Costa, P. T., Jr., 248, 249, 250 Cotter, V. T., 268 Cotton, S. R., 313 Coulston, C. M., 286 Cowan, C. P., 327 Cowan, P. A., 327 Cox, C., 298, 337 Cox, K., 257, 260, 261 Coxon, J. P., 74 Coyle, C. E., 196 Craft, S., 293 Craik, F. I. M., 166 Crampes, M., 210 Cready, C. M., 133 Crisp, R. J., 220, 221 Crivello, F., 52 Crohan, S. E., 323 Crohn, H. M., 331 Crosby, L., 326 Cross, E. S., 210 Cross, S., 268 Crown, J. S., 323 Cruickshanks, K. J., 71 Cuijpers, P., 298 Culgin, S., 147 Cummings, N., 318 Cunnane, S. C., 52 Cunningham, W., 13, 191 Curhan, K., 334 Curtin, N., 260 Curtis, R., 332 Czaja, S., 175
Dacks, P. A., 295 Dahlin, E., 50, 198 Dale, A. M., 196 Dale, W., 113 Dalton, C., 131 Dalton, D. S., 71 D’Arcy, C., 196 Das, P., 286 Davies, K., 119 Davies, L., 319 Davies, P. G., 99 Davis, B. W., 150 Davis, S. R., 337
De Andrade, C. E., 211 de Frias, C. M., 173 De Grip, A., 196 De Jager, C. A., 180 De Jong, P., 136 de Jonge, P., 197 De la Monte, S., 294 De La Sayette, V., 178 de Magalhães, J. P., 60, 61 De Paula Couto, M. C. P., 218 de Vries, B., 312 DeAndrea, D. C., 312 Deary, I. J., 100, 250 DeCarli, C., 40, 48 Deck, C., 206 Decker, S. L., 146 Deeg, D. J. H., 99 DeFries, E., 283 DeGroot, D. W., 85 Deib, G., 294 DeKosky, S. T., 289, 291, 293, 294 Dellefield, M. E., 145 DeLuca, S., 202 DelVecchio, W. F., 250 Demir, M., 312 Demler, O., 276, 277 Denburg, N. L., 206, 229 Dennett, D. A., 293 Denney, N. W., 208 Dennis, A., 51 Dennis N. A., 36, 48 DePaulo, B. M., 319 Desgranges, B., 178 Desmond, N., 331 DeSoto, K. A., 170 Desrocher, M., 169 Devous, M. D., Sr., 161 Diaz, A., 331 Diaz, M., 171 Diaz-Arrastia, R., 161 Dickson, D., 293 Diehl, M., 133, 208, 254, 259, 264 Diersch, N., 210 Dilharreguy, B., 196 Dillaway, H., 82 Dilworth-Anderson, P., 268 Dirk, J., 161 Dismukes, R. K., 167 Dixon, P., 330 Dixon, R. A., 22, 196, 211, 239 Do Nguyen, A. Q., 130 Dobbs, D., 150 Dodge, H. H., 52 Dommaraju, P., 316 Doniger, G. M., 177 Donnellan, M. B., 250 Dörner, J., 251 Doskow, E., 332 Doubeni, C. A., 96 Douglas, E. M., 318 Doumas, M., 74 Doyle, K. O., Jr., 190 Doyle, W. J., 103 Draper, B., 300 Dreman, S., 324 Drouet, V., 290 Duarte, A., 170, 171 Dubois, B., 293
44918_name index_ptg01_hr_I-1-I-8.indd I-244918_name index_ptg01_hr_I-1-I-8.indd I-2 28/12/13 9:08 AM28/12/13 9:08 AM
Copyright 2015 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
NAME INDEX I-3
DuBois, P. H., 190 Ducharme, F., 144 Duff, M., 178 Duflo, E., 8 Dufour, A., 73 Dugan, E., 196 Dugdale, D. C., 84 Dulas, M. R., 170, 171 Dumas, J. A., 82 Dumke, H. A., 208 Duncan, L. E., 259 Dunlosky, J., 166, 173, 174 Dunn, T. R., 258 Duong, M-T., 86 Dupre, M. E., 132 Dupuis, S., 331 Durmysheva, Y., 211 Dutta, D., 60 Dutton, W. H., 315 Dvorak, J., 179 Dwivedi, Y., 197 Dworkis, D. A., 117 Dwyer, J. T., 169
Earles, J. L., 161 Eastwick, P. W., 315 Eaton, J., 210 Ebner, N. C., 218, 233 Echt, K. V., 278 Eckhardt, C., 317 Edelstein, B., 177, 279, 297 Effros, R. B., 101, 102 Ehlert, U., 103 Eichenbaum, H., 177 Einstein, G. O., 161, 167 Ekerdt, D. J., 131, 139 El Haber, N., 64, 74 Elias, J., 198 Ellemberg, D., 178 Ellis, J. W., 337 Ellison, N. B., 312 Emanuel, L. L., 151 Emery, L., 226, 228 Emul, M., 301 Engels, A. S., 265, 266, 267 Ennis, G. E., 206, 207 Epel, E., 59, 60 Erber, J. T., 219 Ercoli, L. M., 174 Erickson, K. I., 51 Erikson, E. H., 254, 255, 256,
258, 260 Eslick, G. D., 294 Estrada-Manilla, C., 170 Etezadi, S., 212 Etten, M. J., 84 Evans, D., 153, 197 Evans, G. D., 330 Evans, L. K., 147 Eyal, N., 171
Faber, A. J., 328 Facal, D., 165 Fagan, A. M., 293 Fallon, E., 197 Fan, J., 205 Fänge, A. M., 130 Farina, F., 178
Fastame, M. C., 222, 236 Fauth, E. B., 117, 119 Feeny, D. H., 121 Fein, E., 314, 315 Feinberg, L., 333 Feld, S., 139 Feldman, H. A., 293 Feldman, H. H., 291 Feldman, K., 332 Feldman, L., 117 Felling, A. J. A., 325 Feltz, A., 151 Femia, E., 119, 299 Feng, Q., 119 Feng, Z., 143 Fennell, M. L., 143 Ferraro, K. F., 121 Ferrucci, L., 221 Fields, R. D., 177 Figueiredo, B., 327 Fillit, H. M., 295 Fincham, F. D., 323, 326, 327 Fingerman, K. L., 240, 332 Fink, A., 195 Finkel, E. J., 315 Finkel, T., 60 Fiore, A., 312 Fisher, G., 178, 296, 297 Fisher, J. E., 130 Fisher, L. L., 83, 84 Fiske, S. T., 3 Fitzgerald, J. M., 170 Fitzwater, E. L., 301, 302 Flap, H., 314 Flegal, K. E., 167 Fletcher, E., 40 Florsheim, P., 324 Flynn, E., 22 Flynn, H. K., 311 Fogarty, K., 330 Folkman, S., 104 Fonarow, G. C., 80 Forester, B., 303 Foss, J. W., 174 Fossati, P., 44, 45 Foubert-Samier, A., 196 Fowler, B. J., 70 Fox, N. C., 293 Fraccaroli, F., 218 Frank, E., 103 Fraser, G. E., 169 Frazier, L. D., 268 Frei, B., 52 Freitas, A. A., 60, 61 Fretz, B. R., 210 Freund, A. M., 233, 237 Fried, L. P., 233, 234 Friedman, E. M., 333 Friedman, M. C., 173 Friston, K. J., 165 Frith, C. D., 223, 226 Frith, U., 223, 226 Fronczek, R., 86 Fruhauf, C. A., 335, 336 Fuentealba, L. C., 50 Fuentes, A., 169 Fujiwara, S., 63 Fuligni, A. J., 331
Fuller-Thompson, E., 102, 337 Fulton, E. K., 166
Gaines, J. M., 174 Galenkamp, H., 99 Gallagher, A., 145 Gallagher-Thompson, D., 296 Gallois, C., 148 Gamble, W. C., 331 Gandy, S., 289, 291, 294 Ganiron, E. E., 321 Gans, D., 333 Garcia, J. R., 315 Gardner, B. K., 286 Gardner, J., 169 Garner, A. S., 107 Garner, R., 121 Gatz, M., 281 Gaugler, J. E., 133 Gaunt, R., 44 Gefen, D., 312 Geffner, R., 317 George, L. K., 269 Germain, C. M., 228 Gerolimatos, L. A., 279 Gerstorf, D., 239 Giblin, S., 303 Gibson, R. C., 278 Gilbert, D. T., 44, 229, 230 Gilding, M., 313 Giles, H., 148 Gillick, M. R., 145, 151 Gilliver, M., 71 Gillum, B., 250 Gillum, R., 250 Gilmer, D. F., 62, 63, 67, 68, 74 Giordano, J., 36 Giovanello, K. S., 166, 171 Gitlin, L., 137, 295 Givens, J. L., 146 Givertz, M., 322 Gjonça, E., 70 Gladding, S. T., 336 Glaser, R., 103, 107 Glorioso, D. K., 222 Glück, J., 211 Glymour, M. M., 196 Go, A. S., 77 Goble, D. J., 74 Goguen, L. A., 264 Goh, J. O., 48 Golant, S. M., 130, 136, 139, 141 Gold, D. A., 119 Goldberg, A. E., 332 Goldstein, D., 101, 102 Goldstein, E. G., 259 Goldston, R. B., 203 Golub, R. M., 71 Gómez-Fernández, T., 170 Gonyea, J. G., 335, 336 Gonzalez, E. W., 268 Goode, P. S., 113 Goodman, C., 337 Goodwin, P.Y., 320 Gorenstein, E. E., 147 Goronzy, J. J., 102 Gorree, E., 169 Goto, S., 95
Gottman, J. M., 326 Gouin, J.-P., 103 Gould, C. E., 279, 280, 281 Gould, S. J., 238 Gouze, M., 250 Gow, A. J., 100 Grabowski, D. C., 146 Grady, C., 36, 46, 47, 48, 49, 161,
165, 170, 171 Graf, N. L., 320 Graham, E. K., 247, 251, 260 Granacher, U., 74 Grant, B. F., 304 Grau-Sepulveda, M. V., 80 Green, E. E., 173 Greenberg, D. L., 170 Greenfield, E. A., 313, 328, 337 Gretebeck, K. A., 121 Gretebeck, R. J., 121 Greto, E., 102 Greving, K. A., 323, 329 Grey, R., 174 Griffin, M., 67 Griffith, J., 144 Grigorenko, E. L., 187, 190 Grimm, K. J., 196 Groger, L., 146 Gross, A. L., 174 Grossmann, I., 203, 211 Gruber, M., 74 Gruenewald, T. L., 258 Grühn, D., 203, 234, 251, 254,
259, 260 Gruneir, A., 146 Gu, D., 132, 269 Gu, X., 205 Gubernskaya, Z., 330 Gudmundsdottir, M., 82 Guergova, S., 73 Guerreiro, J. D. T., 180 Guiaux, M., 328 Guidotti Breting, L. M., 34 Guihan, M., 140 Guilford, J. P., 248 Guy, D., 296
Hacker, M., 114, 115 Hagler, D. J., Jr., 196 Hahn, A., 60 Haier, R. J., 46, 194 Hainselin, M., 178 Halaas, G. W., 144 Hale, J. L., 314 Haley, W. E., 296, 324, 325,
333, 334 Halford, W. K., 326, 327 Hall, S. S., 322 Halpern-Meekin, S., 320 Han, S. D., 34 Hannequin, D., 178 Hansen, S. R., 314 Hansen, T., 322, 323 Hanzal, A., 322 Hareven, T. K., 332 Harley, C. B., 60 Harris, R. L., 259 Harris-Kojetin, L., 146 Harrison, J. D., 131
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Copyright 2015 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
I-4 NAME INDEX
Hart, H. M., 257 Hartman, P. S., 211 Harwood, J., 148, 149 Hasher, L., 161, 234 Hashimoto, K., 284 Haslam, C., 176 Hassan, Z., 319 Hasselmo, K., 312 Hastie, R., 206 Hattori, M., 95 Havaldar, R., 63, 64 Haw, C., 279 Hawton, K., 279 Hayflick, L., 59, 60, 95, 97 Hayslip, B., 197 Hayslip, B., Jr., 218, 337 Hayward, M. D., 324 Hebrank, A. C., 161 Heckhausen, J., 236, 237 Heeringa, S., 178 Hehman, J. A., 148, 220, 221 Heller, W., 265, 266, 267 Helmer, C., 52, 196 Helmers, K. F., 198 Helson, R., 251 Henderson, S., 313 Henderson-Wilson, C., 332 Hendriks, A. A. J., 250 Hendriks, G.-J., 302 Henkin, R. I., 75 Henry, J. D., 222, 228, 229 Henry, N. J. M., 324 Hepp, J., 167 Herbig, U., 95 Hernandez, D. G., 294 Hernández-Ramos, E., 170 Herrington, J. D., 265, 266, 267 Hersch, G., 145 Hershey, D. A., 206 Hertz, F., 332 Hertzog, C., 22, 162, 165, 166, 173,
174, 175, 195, 196, 197, 222, 223, 230, 236
Hess, T. M., 172, 207, 217, 224, 225, 226, 227, 228, 232
Hess, U., 226 Heyl, V., 71, 133, 137 Higby, H. R., 120 Hill, P. L., 251 Hillcoat-Nalletamby, S., 8 Hills, L., 257 Hills, W. E., 336 Hines, D. A., 318 Hirakawa, M., 95 Hirschman, J., 100 Hirschtick, J., 100 Hirst, W., 240 Hirve, S., 99 Hitchcock, R., 16 Hodder, K. I., 176 Hodges, E. A., 228 Hoenig, H., 119 Hof, P. R., 205 Hofer, S. M., 192, 194, 208 Holland, D., 196 Holland, K., 121, 222 Holmes, A., 170 Holmes, P., 151
Holton, E. F., 210 Homma, A., 331 Hommel, B., 162 Honeycutt, J. M., 150 Hoogduin, C. A. L., 302 Hooker, K., 247, 253, 268, 324 Hoppmann, C., 239 Horhota, M., 173, 217, 223, 231 Horn, J. L., 191, 192, 193, 194,
208, 210 Houser, A., 333 Houx, P. J. H., 196 Howard, D. V., 164 Howard, J. H., Jr., 164 Howe, A. L., 139 Howieson, D., 52 Hoyles, K., 299 Hsiao, W.-H., 313 Hsu, H.-C., 265 Hu, M. Y., 220 Hubbard, R. R., 331 Huettel, S. A., 41, 42, 43 Huffman, D., 59, 171, 229 Huguet, P., 172 Huisman, M., 99 Hull, T. H., 319 Hultsch, D. F., 195, 211 Hummert, M. L., 218, 220, 221, 222 Hunter, C. E. A., 15, 174, 176, 297 Hunter, E., 135 Huston, T. L., 323 Huyck, M. H., 259 Hwang, K. S., 300 Hyman, B. T., 293
Ibrahim, R., 319 Igarashi, H., 129, 324 Iglesias, J., 37 Ihle, A., 168 Imoscopi, A., 75 Inelmen, E. M., 75 Ingersoll-Dayton, B., 325 Irwin, M. R., 102 Isaacowitz, D. M., 45, 228, 233,
234, 235 Isaacs-Shockley, M., 330 Ishler, K. J., 105 Itoh, M., 95 Iwarsson, S., 130, 131, 137 Izumi, S., 211
Jack, C. R., Jr., 293 Jackson, J. S., 278 Jacobs-Lawson, J. M., 206 Jacoby, L. L., 171 Jagger, C., 119 Jagoda, A., 179 Jagust, W. J., 40 Jain, E., 203 Jainer, A. K., 285 Jak, A. J., 35 Janicki-Deverts, D., 103, 106 Jansen, A., 166 Janssen, J., 210 Jarrott, S. E., 299 Jarvin, L., 187, 190 Jaspal, R., 12 Jefferson, A., 299
Jenkins, K. R., 324 Jeon, S., 147 Jeste, D. V., 222, 281, 287 Jette, A. M., 117, 118, 119, 120, 121 Jewell, R. D., 220 Jin, R., 276, 277 Jobe, J. B., 198 Johansen-Berg, H., 51, 177 Johansson, B., 119 Johnson, B., 171 Johnson, M. A., 280 Johnson, M. K., 171 Johnson, M. M., 152 Johnson, T. L., 161 Johnson, T. M., 113 Johnson, W., 250 Johnston, K., 179, 332 Jokela, M., 323 Jolles, J., 196 Jonasdottir, S., 70 Jones, A., 139, 146 Jones, B. F., 210, 211, 319 Jones, D. H., 323 Jones, R., 134, 198, 199 Jonsdottir, I., 294 Jonsson, P. V., 294 Jonsson, T., 294 Juang, L., 12 Juffer, F., 332 Juncos-Rabadán, O., 165 Jung, R. E., 46, 194, 211 Juraska, J. M., 37, 40, 41, 46, 49 Juvekar, S., 99
Kaasik, P., 63 Kahana, B., 131, 132 Kahana, E., 131, 132 Kahlbaugh, P. E., 203 Kail, R., 322 Kales, H. C., 295 Kalish, K., 177, 281 Kallio, E., 203 Kalmijn, M., 314 Kalpouzos, G., 166, 177 Kamatchi, R., 285 Kampman, M., 302 Kane, R. A., 152 Kane, R. L., 112, 133 Kanehisa, M., 95, 96 Kanekiyo, T., 294 Kaplan, G. A., 120 Kaplan, M. S., 121 Kapp, M. B., 151, 152 Kapur, N., 175 Karamouti, M. V., 112 Karasawa, M., 211, 334 Karasu, S. R., 324 Karasu, T. B., 324 Karel, M. J., 281 Karim, S. S., 100 Karney, B. R., 322, 323 Karp, J. F., 113 Karpel, M. E., 171 Kasagi, F., 63 Kasl, S. V., 222 Kasuya, H., 63 Kaszniak, A. W., 43 Katayama, T., 95
Kaur, A., 283 Kavanagh, L., 228 Kavé, G., 171 Kawakami, N., 334 Kawas, C., 293 Kawashima, S., 95 Kazanis, I., 51 Kegan, R., 264 Keijsers, G. P. J., 302 Keinan, G., 234 Kelley, K., 246 Kelley-Moore, J., 117, 132 Kelly, J. F., 196, 197 Kelly, M., 297 Kemeny, M., 60 Kennedy, H. P., 82 Kennedy, K. M., 161 Kenney, W. L., 85 Kennison. R. F., 195 Kensinger, E. A., 43, 44, 45, 234 Kessels, R. P. C., 164 Kessler, R. C., 276, 277 Ketelaar, T., 313 Kiang, L., 331 Kiecolt-Glaser, J., 103 Kilson, M., 331 Kim, H. K., 326 Kim, S., 161, 207, 279 Kim, W., 300 Kimbler, K. J., 161, 239 King, A., 147 King, P. M., 202, 203 King, S. V., 336 King- Hoope, B., 70 Kingma, E. M., 197 Kingston, A., 119 Kinney, J. M., 105, 325 Kinsella, G. J., 176, 297 Kinsella, K., 96 Kippen, R., 322 Kircher, T. T., 166 Kirkpatrick, L. A., 313 Kisley, M. A., 234 Kitayama, S., 211, 334 Kitchener, K. S., 202, 203 Kivett, V. R., 336 Klaczynski, P. A., 232 Kleck, R. E., 226 Klein, B. E. K., 71 Klein, R., 71 Klein, S. A., 167 Kliegel, M., 168 Kliegl, R., 50 Kline, S. L., 320 Klochkov, T., 102 Klug, M. G., 144 Knight, B. G., 334 Knopman, D. S., 293 Knowles, M. S., 210 Knox, V., 327 Knudsen, K., 300 Knutsen, S. F., 169 Ko, J. Y., 174 Koenig, B. L., 313 Koepke, K. M., 198 Koestner, B., 229 Koistinen, P., 60 Koller, S. H., 218
44918_name index_ptg01_hr_I-1-I-8.indd I-444918_name index_ptg01_hr_I-1-I-8.indd I-4 28/12/13 9:08 AM28/12/13 9:08 AM
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NAME INDEX I-5
Koorenhof, L., 175 Kornadt, A. E., 225, 264 Koschutnig, K., 195 Kotre, J. N., 256 Kotter-Grühn, D., 224, 225 Kozbelt, A., 211 Krack, P., 300 Krall, E. A., 169 Kramer, A. F., 171, 198 Kramer, D. A., 203 Krampe, R. T., 162 Krause, N., 106, 268, 269 Kraut, M., 294 Krendl, A. C., 234 Kross, E., 203 Krueger, D., 8 Krueger, K. R., 196 Kruglanski, A. W., 235 Krut, J. J., 289 Kryzch, V., 61 Kueider, A. M., 174 Kuhlmann, B. G., 170 Kulik, L., 324 Kulwicki, A. D., 318 Kumar, S. L. H., 283 Kunda, Z., 220 Kunik, M. E., 291 Kunkle, F., 137 Kunz, J. A., 211 Kunzmann, U., 211, 250, 251 Kurdek, L. A., 320 Kwan, V. S. V., 251 Kwon, S., 144 Kyulo, N. L., 169
LaBar, K. S., 41, 42, 43 Labat-Robert, J., 62 Laberge, A.-M., 109 Labouvie-Vief, G., 201, 203, 204,
251, 254, 259, 264 Lachman, M. E., 173, 197, 235,
237, 247, 251, 253, 259, 260 Ladd, F., 331 Ladin, K., 283 Lai, C. K. Y., 296 Lai, D. W. L., 333 Laiyemo, A. O., 96 Lamanna, M. A., 319, 323, 324 Lambert-Pandraud, E., 206 Lamela, D., 327 Lampkin-Hunter, T., 331 Landis, M., 324, 326 Landman, B. A., 294 Lane, E., 299 Lane, R. D., 234 Lane, R. F., 295 Lang, F. R., 225, 264 Langa, K., 178 Langer, E., 144, 221 Lansford, J. E., 312 Lapersonne, 206 LaRose, R., 312 Larsson, A., 50, 198 Larsson, M., 170 Lassonde, M., 178 Laurent, G., 206 Lawlor, B. A., 285 Lawlor, D., 144
Lawton, M. P., 100, 129, 130 Lazarus, R. S., 104 Le Couteur, D. G., 115 Leclerc, C. M., 228 Leclerc, S., 178 LeDoux, J. A., 161 Leduc, N., 109 Lee, E.-K. O., 269 Lee, H. Y., 279 Lee, K. H., 44 Lee, K. S., 333 Lee, R. E., 16 Lee, S. A., 336 Lee, T.-S., 293 Leentjens, A. F., 287 Leeuwenburgh, C., 60 Leidig, T., 210 Leifheit-Limson, E., 222 Leighton, E. A., 234 Leiva, A., 62 Lele, P., 99 Lemieux, A., 201, 202 Lemieux, R., 314 Leon, G. R., 250 Lerner, R. M., 10 LeRoux, H., 130 Leube, D. T., 166 Leveck, M. D., 198 Levenson, R. W., 326 Levin, J., 269 Levine, A. D., 320 Levine, I. S., 313 Levinger, G., 312 Levinson, D. J., 258 Levinson, J. D., 258 Levy, B. R., 221, 222 Lewinsohn, P. M., 286 Lewis, C., 22 Lewis, K. L., 195 Li, D., 283 Li, F., 74 Li, K. Z. H., 162, 233 Liao, D. H., 258 Lichtenberg, P. A., 130 Lieberman, M. D.,, 44 Light, L. L., 164, 165, 166 Li-Korotky, H.-S., 71, 72 Lilgendahl, J. P., 261, 262 Lilley, L., 115 Lim, T.-S., 148 Lin, J., 59, 60 Linden, D. E. J., 34 Lindenberger, U., 160, 162, 165,
218, 239 Lindley, R. I., 117 Lineweaver, T., 173 Lipp, I., 195 Liu, C.-C., 294 Liu, G., 132 Liu, K.-H., 296 Liu, L., 290 Liu, X., 205 Livingston, G., 318 Lloyd, L., 10 Lloyd-Jones, D. M., 77 Lo, M., 316 Loaiza, V. M., 163, 164 Löckenhoff, C. E., 207
Logan, R. D., 256 Londoño-Vallejo, J. A., 60, 109 Long, B. A., 219 Long, M. V., 196, 250 Longest, K. C., 99 Longo, B., 102 López Turley, R. N., 331 Lorayne, H., 158 Lou, V. W. Q., 133 Lövdén, M., 160, 198 Lowry, N. C., 38, 40, 41, 46, 49 Lu, T., 60 Lubart, T. I., 210 Luca, A., 278 Luca, M., 278 Lucas, R. E., 250 Lucero-Liu, A. A., 331 Ludwig, A., 8 Lui, W., 296 Lumley, M. A., 254 Lunkenbein, S., 60 Luong, C., 168 Lustig, C., 167 Lutz, A., 269 Lyketsos, C. G., 295 Lynm, C., 71
MacDonald, S. W. S., 195, 196 Mace, J. H., 170 Mackenzie, P., 60 MacLean, M. J., 148 MacLullich, A. M. J., 287 Macoun, D., 71 Macpherson, H., 198 Madden, D. J., 40, 41, 42, 43 Madeo, A., 139 Magai, C., 313 Magalhães, J., 171 Magnotta, V., 178 Mahady, G. B., 82 Maher, J., 149 Maiden, R. J., 337 Maillard, P., 52 Mair, C. A., 132 Major, J. M., 96 Mak, T., 101 Malarkey, W. B., 103 Malhi, G. S., 286 Malmberg, B., 117, 119 Malmstrom, T. K., 99 Malone, M., 297 Malone, P. S., 229, 230 Mambourg, F., 140 Mandviwala, L., 166 Manji, H., 301 Manoogian, M. M., 324 Manzato, E., 75 Manzel, K., 229 Margrett, J. A., 161, 239 Markland, A. D., 113 Markopoulos, G., 164 Markus, H., 268, 334 Marques-Aleixo, I., 171 Marsiske, M., 198, 199, 208 Marteau, T. M., 295 Martin, A. S., 222 Martin, M., 195, 196, 250, 324 Martin, P., 106, 280
Martin, R., 198 Martinaud, O., 178 Martinez, R. A., 285 Martinez-Galindo, J. G., 170 Maruna, S., 257 Maruyama, L., 218 Marx, K., 174 Marzanski, M., 285 Marzetti, E., 60 Massey, S. G., 315 Mastel- Smith, B., 145 Masunaga, H., 210 Masunari, N., 63 Mather, M., 171, 229, 234 Matsumoto, D., 12 Matusko, N., 276 Matzen, L. E., 171 May, C. P., 234 Mayes, A. R., 177 Mayordomo, T., 106 Mazerolle, M., 172 Mazzarella, S. R., 315 McAdams, D. P., 247, 252, 253,
257, 258, 260, 261, 262 McArdle, J. J., 196 McCabe, D. P., 163, 164 McCann, R. M., 150 McCrae, R. R., 248, 249, 250, 252 McCrate, F. M., 100 McCrory, P., 179 McCullough, B. M., 313 McCune, E. A., 218 McDaniel, M. A., 167, 168 McDonald, D. D., 147 McDowd, J. M., 160 McEvoy, L. K., 196 McFarland, B., 121 McGarry, K., 328 McGee, W., 80 McGillivray, S., 172 McGuire, L. C., 175 McGuire, T. G., 278 McKay, K., 331 McKenzie, P. T., 322 McKhann, G. M., 293 McKinlay, J. B., 84 McKinney, B. C., 284 McKinstry, B., 175 McKitrick, L. A., 174 McLean, K. C., 261, 262 McQueen, M. B., 295 McShane, R. E., 139 Meade, M. L., 239 Meeuwisse, W., 179 Mehta, K. K., 269 Meijer, L., 164 Meijer A. M., 323, 329 Meiser, T., 170 Meléndez, J. C., 106 Meltzer, T., 269 Menchola, M., 43 Mendes de Leon, C. F., 197 Meng X., 196 Menon, U., 259 Merakangas, K., 276, 277 Mercado-Crespo, M. C., 283 Meredith, S. D., 148 Merriam, S. B., 258
44918_name index_ptg01_hr_I-1-I-8.indd I-544918_name index_ptg01_hr_I-1-I-8.indd I-5 28/12/13 9:08 AM28/12/13 9:08 AM
Copyright 2015 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
I-6 NAME INDEX
Merriwether, A. M., 315 Messer, W. S., 114 Messina, V., 278 Meyer, B. J. F., 206 Meyer, J. F., 331 Meza-Kubo, V., 134 Mickler, C., 251 Mienaltowski, A., 209, 217, 232 Miguel, J., 59 Mikels, J. A., 47, 48, 188, 207,
217, 234 Milaszewski, D., 102 Miller, D. K., 99 Miller, G. E., 103 Miller, J. P., 99 Miller, K. I., 334 Miller, K. J., 174 Miller, L. M. S., 240 Miller, T. R., 99 Minnotte, K. L., 321 Miotto, F., 75 Miranda, J., 278 Missildine, W., 321 Mitchell, B. A., 332, 333 Mitchell, K. J., 171 Mitchell, S. L., 146 Mohanty, A., 265, 266, 267 Mohlman, J., 147 Mohr, B. A., 84 Mohr, C., 48 Mojon, D. S., 69 Mojon-Azzi, S. M., 69, 70 Mok, E., 139 Molchan, S. E., 285 Molloy, M., 179 Molony, S. L., 147 Moore, K. D., 130 Moorman, S. M., 313, 328, 337 Mor, V., 143 Morán, A. L., 134 Morcom, A. M., 165 Moreira, P. I., 171 Morel, S., 164 Morfei, M. Z., 268 Morgan, D., 269 Morgan, S., 144 Morian, A., 175 Moriarty, J., 151 Morisset, P., 172 Morrell, R. W., 278 Morris, J. N., 175, 198, 199 Morris, M. C., 197 Morris, W. L., 319 Morrow, D. G., 239 Morycz, R., 312 Mosher, W. D., 320 Mossello, E., 139 Most, E., 86 Mõttus, R., 250, 251 Moum, T., 322 Mouras, H., 203, 254 Mouzon, D., 278, 279 Moyle, W., 147 Moynehan, J., 323 Muehlbauer, T., 74 Mueser, K. T., 303 Mühlig-Versen, A., 250, 251 Mulley, G., 283, 284 Munavalli, G. S., 62
Muntaner, C., 278 Murachver, T., 318 Murray, C. J. L., 153 Musil, C. M., 337 Mutchler, J. E., 336 Muus, K., 144 Muzumdar, R. H., 59 Mwanyangala, M. A., 265
Na, J., 211 Nadel, L., 234 Nahemow, L., 129 Nakamura, T., 63 Nalls, M., 294 Nam, J. H., 279 Nashiro, K., 171, 229 Naveh-Benjamin, M., 163, 171 Navis, S., 283 Nazroo, J., 70 Neely, S. A., 50 Neff, L. A., 323 Neft, N., 320 Neisser, U., 159, 169, 170 Nelson, A. J., 226 Nerenberg, L., 318 Neugarten, B. L., 335 Neumann, C. S., 337 Neuville, J., 70 Newcomer, R., 133 Newsom, J. T., 334, 335 Newton, N. J., 247, 259, 260 Newton, P. M., 259 Ng, J. W., 133 Ng, S. H., 148 Nguyen, C. M., 206 Nichols, L. O., 296 Nigro, N., 83 Niki, K., 234 Nilsson, L.G., 165 Niparko, J. K., 71 Nisbett, R. E., 195 Nizard, C., 61 Nokes, T. J., 239 Nondahl, D. M., 71 Noonan, D., 71 Nordahl, C. W., 40 Nordin, S., 75 Norem, J. K., 253 Noristani, H. N., 39 Norlander, B., 317 North, M. S., 3 Nosek, M., 82 Nouri, K., 62 Nurius, P., 268 Nyberg, L., 39, 50, 160, 161, 165,
166, 198
Obernier, K., 50 O’Brien, L. T., 218, 222 O’Brien, R. J., 294 Oburu, P. O., 337 O’Connor, D. W., 286 O’Dell, C. D., 298 O’Donovan, A., 60, 103 O’Dwyer, S., 147 Oedekove , C. S. H., 166 Ogden, J., 99, 107 Oh, D. H., 279 O’Hanlon, A. M., 174
Ohta, N., 163 Okuda, S., 95 Old, S., 171 O’Leary, K. D., 317 Olivares, E. I., 37 Oliveira, P. J., 171 Olson, B. D., 252, 253, 257, 258,
260, 261 Oosterman, J. M., 164 Orange, J. B., 148 Orel, N. A., 335 O’Riley, A., 279 Ormel, J., 197 O’Rourke, N., 324 Orwoll, L., 264 Osgood, D. W., 333 Ositelu, M., 173 Ossher, L., 167 Oswald, A. J., 265 Oswald, F., 26, 135, 137 Ota, H., 148, 150 Ott, D. V. M., 211 Owen, C. J., 332 Ownby, R. L., 175 Ozawa, M. N., 327
Packer, D. J., 268 Paice, J., 113 Palkovitz, R., 330 Palm, G., 330 Palmer, B. W., 281, 287 Palmérus, K., 337 Palmisano-Mills, C., 147 Palmore, E. B., 61 Pan, W., 80 Papaioannou, P. D., 112 Papp, L. A., 147 Pargament, K. I., 105 Paris, D. L., 145 Parish, J. M., 174 Parisi, J. M., 174 Park, C. L., 268 Park, J., 334 Park, Y., 96 Park, Y.-H., 139 Park D. C., 47, 48, 49, 188 Parker, L. D., 325 Parkman, A. M., 323 Parks, S. M., 151 Parrot, A., 318 Passalacqua, S. A., 148 Passarella, S., 86 Pasternak, O., 177 Pasupathi, M., 170, 261, 262 Patel, J., 36 Patrick, J. H., 337 Patterson, A. V., 256 Pattie, A., 100 Paul, R., 299 Pearlin, L. I., 236, 334 Pearson, F., 332 Peltzer, K., 283 Pereiro, A. X., 165 Perls, T., 97, 117 Perrier, E., 61 Persson, J., 166 Peters, E., 206 Peters, R., 268 Peterson, B. E., 259
Peterson, C. B., 130 Peter-Wright, M., 324 Pettinato, J., 143 Peuchant, E., 52 Pezzuti, L., 209 Pfeiffer, E., 237 Phaswana-Mafuya, N., 283 Phillips, D. R., 10, 96 Phillips, J., 8 Piaget, J., 200, 201 Pienta, A. M., 324 Pierson, H. D., 148 Piguet, O., 234 Pillai, J. A., 196 Pillemer, K. A., 332 Pilli, S. C., 63 Pine, K., 22 Pipingas, A., 198 Piquet, B. J., 313 Plassman, B., 178 Platz, E. A., 71 Pletnikova, O., 294 Plonsky, L., 26 Poldrack, R. A., 34 Ponds, R. W. H. M., 196 Poon, L. W., 196, 250, 280 Popenoe, D., 320 Postma, A., 164 Pot, A. M., 298 Potter, G. G., 75 Powell, J. J., 180 Prager, I. G., 219 Prasad, N. R., 130 Prasad, R., 130 Pratt, S. I., 303 Prebble, S. C., 169 Pride, N. B., 81 Prince, M., 288 Prokopiou, J., 196 Prossimo, G., 278 Proust-Lima, C., 52 Ptak, R., 160 Pullen, S. M., 227 Punhani, S., 97 Punnoose, A. R., 71 Purandare, N., 151 Purser, J. L., 119 Pushkar, D., 212 Puterman, E., 60 Putti, B. B., 63 Pynoos, J., 100, 128, 129, 130
Qi, X., 283 Qualls, S. H., 276, 278, 287 Queen, T. L., 206, 207 Quéniart, A., 240 Quine, S., 131 Quinette, P., 178
Rabig, J., 147, 152 Rabin, B. S., 103 Radloff, L. S., 284 Rahhal, T., 172, 234 Rahman, A. N., 152 Raju, S. S., 270 Ramakumar, S., 331 Ramos-Zúñiga, R., 51 Randall, G. K., 280 Rando, T. A., 96
44918_name index_ptg01_hr_I-1-I-8.indd I-644918_name index_ptg01_hr_I-1-I-8.indd I-6 28/12/13 9:08 AM28/12/13 9:08 AM
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NAME INDEX I-7
Ranganath, C., 40 Rankin, C. T., 320 Ranwez, S., 210 Raschick, M., 325 Rattan, S. I. S., 61, 95 Rau, J., 300 Rauers, A., 239 Rawlins, W. K., 312 Ray, R. D., 44, 46 Raye, C. L., 171 Raymann, R. J. E. M., 86 Ready, R. E., 264 Reamy, A. M., 152 Rebok, G. W., 198, 199 Redzanowski, U., 211 Reed, A. E., 233, 234, 313 Reese, D., 145 Reese-Melancon, C., 222 Reeves, L. M., 163 Reeves, M. J., 80 Régner, I., 172 Reiber, C., 315 Reichard, C. C., 174 Reid, R. C., 146 Reinhard, S. C., 333 Reinhold, S., 283 Reinke, B. J., 259 Reishofer, G., 195 Reitz, C., 294 Remedios, J. D., 268 Rendeiro, C., 179 Rendell, P. G., 168 Renner, V. J., 276 Renshaw, K. D., 323 Repovs, G., 205 Reuter-Lorenz, P. A., 47, 49, 188 Rhoades, G. K., 320 Rhodes, M. G., 171 Rhodes, R., 152 Rich, K. L., 151 Richards, M., 180 Rickard, A. P., 180 Riddle, R. R., 218 Ridings, C., 312 Ridley, N. J., 300 Rieck, J. R., 161 Riediger, M., 218, 233, 239 Riedmann, A., 319, 323, 324 Rieger, M., 210 Rigalleau, F., 172 Rijken, A. J., 329 Riklund, K., 160 Riley, L. D., 332 Riso, E.-M., 63 Ritter, J. O., 237 Rizzuto, T. E., 161 Robert, A. A., 62 Robert, L., 62 Roberto, K. A., 299, 311, 312, 313 Roberts, B. W., 250, 251 Roberts, P., 259 Robertson, K., 318 Robinson, A., 139 Robinson, B., 232 Robinson, G. E., 145 Robinson, L., 119 Röcke, C., 235, 253 Rockwell, J., 152 Rockwood, K., 113, 119
Rodin, J., 144 Rodrigue, K. M., 161 Rodrigues, C., 323 Rodriguez, J. J., 39 Rodriguez, M. S., 165 Roediger, H. L., III., 170 Roger, V., 77 Rogers, C. S., 171 Rokach, R., 324 Romeijn, N., 86 Romeo, S., 278 Rönnlund, M., 165 Roper, L. L., 331 Rose, N. S., 166 Rosen, J., 71 Rosenberg, D. C., 228 Rosenberg, S. D., 259 Rosenfield, S., 278, 279 Rosmalen, J. G. M., 197 Rosnick, C., 235 Ross, L. E., 331 Ross, N. A., 121 Ross, P. D. S., 151 Roth, D. L., 296 Rothberg, S. T., 219 Rothblum, E. D., 320, 321 Rothermund, K., 225, 264 Rouwendal, J., 136 Rowe, G., 164 Rowles, G., 135 Rowles, G. D., 135 Roy, A., 97 Royzman, E. B., 234 Rozin, P., 234 Ruckh, J. M., 50 Rudolph, C. W., 233 Rudow, G., 294 Rummel, J., 167 Rutherford, A., 164 Rutter, D., 151 Ryan, E. B., 147, 148, 149 Rye, M. S., 327
Saavedra, C., 37 Sabia, S., 195 Saczynski, J. S., 174 Saigal, S. D., 315 Saijonmaa, O., 60 Sakaki, M., 171, 229, 234 Sakraida, T. J., 327 Salai, L. K., 302, 303 Salari, P., 66 Salari, S., 210 Salmon, D. P., 196 Salthouse, T. A., 37, 160 Samayoa, S., 151 Sambhudas, S., 99 Samieri, C., 52 Sampson, E. L., 151 Sancho, P., 106 Sanfey, A. G., 206 Sanford, D. A., 96 Sarangi, S., 206 Saribay, S. A., 229 Sasson, E., 177 Sauceda, J. A., 116, 167 Saunders, K., 279 Saunders, M., 101 Savci, E., 332
Savela, S., 60 Saver, J. L., 80 Savla, G. N., 222 Saxon, S. V., 84 Sayegh, P., 334 Schacter, D. L., 166, 171 Schaefer, S., 162 Schaie, K. W., 24, 25, 37, 134, 186,
188, 195, 196, 197, 198, 208, 224, 263
Scheibe, S., 45, 211 Scheidt, R. J., 135, 136, 137, 139, 141 Scheier, M. F., 312 Schilling, O., 71, 137 Schim, S. M., 268 Schmiedek, F., 161, 239 Schmitt, D. P., 315, 316 Schnebert, S., 61 Schneider, J. A., 196, 197 Schneider, S., 314, 315 Schnelle, J. F., 152 Schnitzspahn, K., 168 Schoeneman, K., 153 Schoeni, R. F., 328 Schoklitsch, A., 258 Schooler, K. K., 132, 133 Schootman, M., 96, 99 Schuepbach, W. M. M., 300 Schulz, P., 291 Schulz, R., 236, 312 Schütz-Bosbach, S., 210 Schwartz, C. R., 320 Schwarz, B., 135, 136, 137, 139, 141 Scuderi, C., 289 Scullin, M. K., 168 Seay, R., 209, 232 Sebastiani, P., 117 Seeman, T. E., 258 Seene, T., 63 Segal, D. L., 276, 277, 278, 281,
283, 284, 287, 301, 302, 303, 304, 305
Segrin, C., 322 Seltzer, J. A., 333 Selwood, A., 318 Sengupta, M., 146 Seo, J. Y., 279 Sergeant, J. F., 131, 139 Sergi, G., 75 Shamliyan T., 112 Shao, J., 283 Shapiro, A., 322 Sharma, J. C., 299 Sharpe, T., 269 Shaw, R. J., 160 Shea, S. C., 116 Sheehy, G., 258 Shega, J. W., 113 Shema, S. J., 120 Shemmassian, S., 300 Sherman, A. M., 312 Shi, L., 97 Shi, Q., 8 Shield, R. R., 146 Shih, P. C., 194 Shimizu, Y., 171 Shineman, D. W., 295 Shiner, R., 250 Shivapour, S. K., 206
Shoemaker, C., 312 Shonkoff, J. P., 107 Shor, M., 206 Shorek, A., 171 Shrira, A., 234 Shuster, J. L., 151 Shweder, R. A., 259 Sibille, E., 284 Siddarth, P., 174 Siegle, G. J., 44 Silberleitner, N., 167 Silbert, L. C., 52 Silverstein, M., 332 Simoni, J. M., 116, 167 Simonton, D. K., 211 Simpson, T., 198 Sinclair, S., 319 Singh, H., 291 Singh, P. N., 169 Sinnott, J. D., 202 Sirota, K. G., 147 Siu, O.-l., 10 Skevington, S. M., 100 Skrajner, M. J., 297 Skultety, K. M., 263 Slade, M. D., 221, 222 Slater, C. L., 256 Slaug, B., 130 Slominski, T., 175, 297 Small, B. J., 196 Small, S. A., 290 Smith, D. M., 198, 199 Smith, E. E., 80 Smith, G. C., 337 Smith, S., 179 Smith, T. W., 324 Smyer, M. A., 151, 175, 276,
278, 287 Smyke, A. T., 332 Snaedal, J., 294 Sneed, J. R., 263 Sojkova, J., 294 Somashekar, B., 285 Somera, L.,, 149 Soto, J. A., 226 Sousa-Poza, A., 69 Spaniol, J., 46, 47, 165, 170, 171 Sparks, C., 196 Spencer, B., 139 Spencer, J. P. E., 180 Spencer, S. J., 220 Sperling, R. A., 293 Spira, A. P., 174, 297 Spiro, A., 197, 251 Sritharan, R., 315 Srivastava, S., 251 St. Pierre, M., 318 Stadler, W., 210 Stafford, L., 320 Standing, T., 337 Stanley, J. T., 235 Staples, A. M., 147 Starr, J. M., 100 Staudinger, U. M., 211, 212, 250 Steardo, L., 289 Stefansson, H., 294 Steffener, J., 48 Steffens, D. C., 75 Stein, R., 222
44918_name index_ptg01_hr_I-1-I-8.indd I-744918_name index_ptg01_hr_I-1-I-8.indd I-7 28/12/13 9:08 AM28/12/13 9:08 AM
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I-8 NAME INDEX
Steinberg, S., 294 Steinfield, C., 312 Steinman, B. A., 130 Stein-Morrow, E. L., 240 Stephen, A. M., 180 Stern, Y., 48 Sternberg, R. J., 187, 190, 191,
210, 314 Sterns, H. L., 259 Stevens, A., 174, 296 Stevens, J. C., 73 Stewart, A. J., 247, 259, 260 Stigsdotter Neely, A., 198 Stojnov, D., 220 Stoner, S., 279, 280, 281 Stough, C., 198 Straka, L. A., 147 Strandberg, A. Y., 60 Strandberg, T. E., 60 Strawbridge, W. J., 120 Street, D., 140 Ströhle, A., 60 Strough, J., 209, 239 Stula, S., 140 Suitor, J. J., 332 Summers, K., 173 Sun, F., 270 Sun, J., 47 Sunderland, T., 285 Swanson, D. A., 96 Swanson, R. A., 210 Swindell, R., 210 Swinnen, S. P., 74 Symes, L., 145 Szuchman, L. T., 219
Tach, L., 320 Tae, Y.-S., 144 Takahashi, I., 63 Takeuchi, H., 211 Talamini, L. M., 169 Tamayo, G. J., 334 Tang, Y., 197 Tangredi, L. A., 102 Tanious, M., 286 Tanner, J. L., 259 Tarrasch, R., 177 Taylor, J. L., 210 Taylor, R. J., 269, 276 Taylor, S. E., 103 Te Lindert, B., 86 Tennstedt, S. L., 112, 198 Terry, D., 97 Thambisetty, M., 294 Therborn, G., 320 Thiele, D. M., 336 Thoits, P. A., 99 Thomas, A. G., 51 Thomas, F., 327 Thomas, M. D., 140 Thomas, R. C., 161, 234 Thompson, G. E., 337 Thompson, M. M., 235 Thompson, P., 175 Thompson, W. K., 222 Thornton, W. J. L., 208 Tierney, W. M., 99 Tighe, L. A., 240
Tilse, C., 139 Tilvis, R. S., 60 Timmerman, L., 300 Tippett, L. J., 169 Tokimatsu, T., 95 Toles, M., 145 Tomás, J. M., 106 Tomiyama, A. J., 60 Tomolillo, C., 312 Tonello, S., 178 Tong, S., 47 Tonkovic, M., 173 Tonstad, S., 169 Torges, C. M., 259 Torres Stone, R. A., 96 Torres-Trejo, F., 170 Traber, M. G., 52 Tranel, D., 178, 229 Trope, Y., 44 Troutman, M., 269 Truxillo, D. M., 218 Tsuno, N., 331 Tufan, F., 301 Tully, P. J., 283 Tuminello, E. R., 34 Turan, S., 301 Turner, R. N., 220, 221 Tyers, R., 8 Tyler, D. A., 143
Ueno, K., 312 Uleman, J. S., 229 Unverzagt, F., 198, 199
Vagelatos, N. T., 294 Vahia, I. V., 222 Vaillant, C. O., 258 Vaillant, G. E., 258 Valadian, I., 169 van Boxtel, M., 196 Van Dam, N. T., 205 Van Den Wijngaart, M. A. G., 325 van den Wittenboer, G. L. H.,
323, 329 van der Harst, P., 197 Van Der Meijden, W. P., 86 van Dulmen, M., 314 van Hattum, P., 136 Van Impe, A., 74 Van Muijden, J., 162 van Schendel, N., 109 Van Someren, E. J. W., 85 Vander Weg, M. W., 198 Varkal, M. D., 301 Varnum, M. E. W., 211 Vaughan, C. P., 113 Verbrugge, L. M., 117, 118, 119,
120, 121 Vereeck, L., 74 Verkhratsky, A., 39 Vernooij-Dassen, M. J. F. J., 325 Viaro, F., 178 Vintildea, J. C., 59 Voelkle, M. C., 218 Volkman, J., 300 Volkov, B., 144 von Cramon, D. Y., 211 Von Hippel, W., 222, 228, 229
Vorvick, L. J., 82 Voshaar, R. C. O., 302 Voss, A., 165 Voss, M. W., 198 Vranic, A., 173
Wahl, H.-W., 71, 133, 137 Waites, C., 336 Walker, L., 316 Wall, S., 99 Wallace, T., 175 Walsh, T., 145 Walters, E., 276, 277 Walther, A. N., 327 Wang, M., 229 Wang, P., 278 Wang, T.-J., 119 Ward, L., 15, 174, 176 Ward-Pinson, M., 218 Waring, J. D., 44 Warner, D. F., 117 Warner, E., 332 Warren, D. E., 178 Watkins, J. F., 135 Watson, P. W. B., 175 Watts, A., 195 Weaver, D. A., 328 Webb, A. G., 265, 266, 267 Webster, D. M., 235 Webster, M. J., 197 Webster-Marketon, J., 107 Wechsler, D., 186 Weibel-Orlando, J., 336 Weiner, D. K., 113 Weinstein, K. K., 335 Weisberg, R. W., 163 Weiss, D., 225, 264 Weiss, R. A., 62 Wentura, D., 218 West, R. L., 173 Weyand, C. M., 102 Whelan, T. A., 336 Whitbourne, S. K., 20, 73, 147,
262, 263 White, M. L., 268, 269 Whitman, S., 100 Whitty, M. T., 314 Wiebe, J. S., 116, 167 Wijekoon, C., 300 Wiley, T. L., 71 Willander, J., 170 Willems, D., 196 Williams, A., 148, 149 Williams, C. M., 180 Williams, D. R., 278 Williams, K. N., 148 Williams, S. A., 313 Williams, S. P., 291 Williams, W., 71 Willis, S. L., 50, 134, 197,
198, 208 Wilt, J., 257, 258 Winecoff, A., 41, 42, 43, 265 Winkielman, P., 228 Winter, L., 151 Withall, A., 300 Witko, T. M., 330 Witter, M. P., 290
Wixted, J. H., 170 Wolfinger, N. H., 327 Wolinsky, F. D., 99, 198 Wolkove, N., 85, 86 Wong, F. K. Y., 139 Wong, L. F., 296 Wood, S., 234 Woodbridge, S., 337 Woods, S. P., 116, 167 Woodward, A. T., 276, 278 Wrosch, C., 236 Wu, J. W., 290 Wu, S., 265 Wu, Z., 99 Wurtele, S. K., 218 Wyman J., 112
Xiao, J. J., 270 Xu, H., 294 Xu, X., 318
Yalvac, D., 301 Yamada, M., 63 Yamanishi, Y., 95 Yan, Q., 102 Yang, G.-Y., 47 Yap, L. S. Y., 296 Yates, F. A., 174 Yates, P. J., 176 Ybarra, O., 228 Yeatts, D. E., 133 Yeh, I., 228 Yeh, M. A., 220 Yesavage, J. A., 284 Yeung, S. M., 139 Yi, Z., 119 Yngvesson, B., 332 Yoder, L. H., 144 Yonelinas, A. P., 40 Yoon, H. S., 327 Yoon, S. M., 337 Yoon, S. S., 80 York, M., 144 Yu, P., 322 Yu, T., 328
Zacks, R. T., 161 Zahariou, A. G., 112 Zahodne, L. B., 196 Zald, D. H., 44, 46 Zanjani, F., 24 Zarit, J. M., 276, 281, 283, 302 Zarit, S. H., 117, 119, 152, 240, 276,
281, 283, 298, 299, 302 Zatorre, R. J., 177 Zelinski, E. M., 195 Zeng, Y., 269 Zerr, I., 291 Zhan, H. J., 334 Zhang, D., 283 Zhang, J., 131 Zhang, L., 283 Zhang, Q., 283 Zheng, Z., 300 Zimdars, A., 70 Zimprich, D., 195, 250 Zogg, J. B., 116, 167 Zonderman, A. B., 221, 294 Zurlo, K. A., 283
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GLOSSARY/SUBJECT INDEX I-9
Glossary/Subject Index AARP Modern Maturity sexuality
study, 80 Abandonment, 318 ABCDE stages of friendship, 312 Absolutist thinking, 203 Absorption The time needed
for a medication to enter a patient’s bloodstream., 114–115, 125
Abusive relationship A relationship that one partner displays aggressive behavior toward the other partner., 316, 340
Accident prevention, 296 Accommodation Changing one’s
thought to better approxi- mate the world of experi- ence, (ii) Readjustments of goals and aspirations as a way to lessen or neutralize the effects of negative self-evaluations in key domains., 200, 215, 236, 243
Acetylcholine, 39, 295 Activation imaging approach
Attempts to directly link functional brain activity with cognitive behavioral data., 36, 55
ACTIVE (project), 198 Active euthanasia The deliberate
ending of someone’s life., 379, 403
Active life expectancy The age to which one can expect to live independently., 95, 125
Activities of Daily Living (ADLs) Basic self-care tasks such as eating, bathing, toileting, walking, and dressing., 119–120, 125
Acuity, 70 Acute diseases Conditions that
develop over a short period of time and cause a rapid change in health., 103, 125
Adaptation, 131 Adaptation level In Lawton and
Nahemow’s model, the point at which competence and environmental press are in balance., 130, 131, 156
ADC(AIDS dementia complex), 300–301
Adoptive parents, 331–332
Adult day care Designed to provide support, companionship, and certain services during the day., 137–139, 156
Adulthood, 313–314 emerging, 14, 31 friendship in, 312–313 grief, 398–399 love, 314
Aerobic exercise Exercise that places moderate stress on the heart by maintaining a pulse rate between 60 % and 90 % of the person’s maximum heart rate., 51–52, 418–419, 425
Affect, 394 Affordable Care Act, 382 Affordable Health Care, 143 African Americans, 12
activities of daily living, 120 alcohol abuse, 304 cardiovascular disease, 77 caring for spouse/partner, 325 cerebrovascular accident, 79 depression, 276, 278, 283 division of household labor, 362 divorce, 325 ethnic identity, 12 grandparents, 336 HIV, 102 hypertension, 80 life expectancy, 96–97 menopause, 82 nursing home residents, 143, 146 older adults (in U.S.), 7 prostate cancer, 111 religiosity, 268, 269 remarriage, 327 retirement, 368 self-rated health, 97 single parents, 331 singlehood, 319 urinary incontinence, 112 women in labor force, 351 women’s earnings as a percent of
men’s in 2010, 355f See also Race and ethnicity
Age, 13–14 Age discrimination Denying
employment or promotion to a person solely on the basis of age., 356, 373
Age effects One of the three fundamental effects examined in developmental
research along with cohort and time-of-of measurement effects, which reflects the influence of time-dependent processes on development, 20, 30
Age-based double standard When an individual attributes an older person’s failure in memory as more serious than a memory failure observed in a young adult., 219, 243
Ageism The untrue assumption that chronological age is the main determinant of human characteristics and the one age is better than another., 3, 30
Ageless Memory (Lorayne), 158 Aging
biological theories, 58–61 cellular theories, 59–60 forces of development, 11, 60–61 myths and stereotypes, 4 in place, 135–136 primary, 13 programmed-cell-death
theories, 60 rate-of-living theories, 59 secondary, 13 self-perception, 224–225, 244 and stress and coping paradigm,
105–106 successful, 422–424 tertiary, 13
Aging demography global data (65 years and above,
2000), 9f global data (65 years and above,
projected 2030), 9f minority population
(1995–2050), 7f projected population (2025), 6f projected population (2050), 6f projected population (2100), 7f resident population (2000), 5f
Aging ecology, 137–139 adult day care, 137–139 aging in place, 135–136 assisted living, 139–141 auxiliary dwelling unit, 138f congregate housing, 139 decisions, best options, 136 home modification, 137
Agreeableness, 249–250 AIDS, 96, 102
AIDS dementia complex, 300–301 Alcoholism, 304 Alcohol-related dementia, 300 Ali, Muhammad, 299 Alienation The feeling that results
when workers feel that what they are doing is meaningless and that their efforts are devalued, or when they do not see the connection between what they do and the final product., 349, 373
Alzheimer’s disease A disease commonly found in the elderly that is characterized by a decline in memory and a progressive destruction of brain cells (ii)An irreversible form of dementia character- ized by progressive declines in cognitive and bodily functions, eventually result- ing in death; it accounts for about 70% of all cases of dementia., 289–299, 308
behavioral intervention, 295–297 beta-amyloid cascade hypoth-
esis, 294 brain activity, 37 causes, 294–295 diagnosis, 290–293 external memory aids, 175 famous people, 275 internal memory aids, 176 medications, 295 memory aging, 178 nature-nurture issue, 14–15 neurological changes, 289 patient care, 298–299 Pocket Smell Test, 75 secondary aging, 13 serotonin, 39 smell, 75 social policy implications,
305–306 spaced retrieval, 297 symptoms, 290–292
Amygdala The region of the brain, located in the medial-temporal lobe, believed to play a key role in emotion., 38, 55, 265
Angelou, Maya, 246 Angina pectoris A painful condi-
tion caused by temporary restriction of blood flow to the heart, 78, 90
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I-10 GLOSSARY/SUBJECT INDEX
Anniversary reaction Changes in behavior related to feelings of sadness on the anniversary date of a loss., 395, 403
Antiaging medicine, 61 Anticipatory grief Grief
experienced during the period before an expected death occurs that supposedly serves to buffer the impact of the loss when it does come and to facilitate recovery., 394, 403
Antigens, 101 Antioxidants Compounds that
protect cells from the harmful effects of free radicals., 33, 55
Anxiety disorders, 301–302 Aphasia, 79 Appearance, 61–63 Aricept® (donepezil), 295 Arthritis, 66–68 Asian Americans
activities of daily living, 120 adopted children, 332 alcohol abuse, 304 cardiovascular disease, 77 divorce, 325 familism, 331 glass ceiling, 337 grandparents, 337 nursing home residents, 143 religiosity, 269 women’s earnings as a percent of
men’s in 2010, 355f See also Race and ethnicity
Assimilation Using currently available knowledge to make sense out of incoming information., 200, 215
Assimilative activities Exercises that prevent or alleviate losses in domains that are personally relevant for self-esteem and identity., 243
Assisted living facilities Housing options for older adults that provide a supportive living arrangement for people who need assistance with personal care (such as bathing or taking medica- tions) but who are not so impaired physically or cognitively, 139–141
Assisted living facilities Housing options for older adults that provide a supportive living arrangement for people who need assistance with personal care (such as bath- ing or taking medications) but who are not so impaired physically or cognitively that they need 24-hour care., 156
Assisted suicide, 381–382
Assortative mating A theory that people find partners based on their similarity to each other., 314, 340
Atherosclerosis A process by which fat is deposited on the walls of the arteries, 78, 79f, 90
Attention, 160–162 automatic processing, 162 divided, 161 effortful processing, 162 inhibitory loss, 161 processing resources, 161 resources, 161–162
Attributional biases, 230–232 Autobiographical memory
Remembering information and event from your own life., 169–170, 183
Autoimmunity The process by which the immune system begins attacking the body., 102, 125
Automatic processing Processes that are fast, reliable, and insensitive to increased cognitive demands., 162, 183
Autonomic nervous system, 84–86 Autosomal dominant inheritance
patterns A genetic inheri- tance pattern that requires only one gene from either one’s mother or father in order to cause a trait or condition to develop, 294, 308
Average longevity The length of time it takes for half of all people born in a certain year to die., 94, 125
Axon A structure of the neuron that contains neurofibers., 37, 55
Baby-boom generation, 3, 12, 218–219, 346, 407, 410 illus, 412
Backup care Emergency care for dependent children or adults so the employee does not need to lose a day of work., 361, 373
Balance, 63–64, 73–74 Barriers, 345 Battered woman syndrome A
situation in which a woman believes that she cannot leave an abusive relationship and in which she may even go so far as to kill her abuser., 316, 340
Beck Depression Inventory, 284 Behavior therapy A type of psy-
chotherapy that focuses on and attempts to alter current behavior. Underlying causes of the problem may not be addressed., 286, 308
Bereavement The state or condition caused by loss through death., 392, 403
Beta-amyloid A type of protein involved in the formation of neuritic plaques both in normal aging and in Alzheimer’s disease., 289, 290f, 308
Beta-amyloid cascade hypoth- esis The process that beta- amyloid deposits create neuritic plaques, that in turn lead to neurofibrillary tangles, that cause neuronal death and, when this occurs severely enough, Alzheimer’s disease., 294, 309
Binge drinking, 304 Bioethics Study of the interface
between human values and technological advances in health and life sciences., 378, 403
Biological age, 14 Biological forces One of four
basic forces of development that includes all genetic and health-related factors., 11, 30
Biopsychosocial framework Way of organizing the biological, psychological, and socio- cultural forces on human development., 11, 30
Bipolar disorder, 286 Bisphosphonates, 66–67 B-lymphocytes, 101–102 Body build, 63 Body mass index (BMI) A ratio of
body weight and height that is related to total body fat., 421, 425
Body surfaces. See Physical changes
Body temperature, 85 Bones, 64–66 “Boomerang kids”, 333 Brain, 37–38
age-related changes in structure, 39–40
compensation for changes in, 46–47
default network, 48 major structures, 38f Parieto-Frontal Integration
theory, 46 structural changes and executive
functioning, 40 “Brain food”, 52 Brain-derived neurotrophic factor
(BDNF), 284 Breast cancer, 109, 110t Burnout The depletion of one’s
energy and motivation, the loss of occupational ideal- ism, and the feeling of being exploited., 349, 373
Caffeine, 65, 86, 295 Calcium, 65, 66t Calment, Jeanne, 93 Cancer, 108–112
breast, 109, 110t cervical, 110t colorectal, 110t incidence, 109f lung, 110t mortality rates, 109f prostate, 110t–111t, 111–112 screening guidelines, 110t–111t
Cardiovascular diseases, 77–78 Cardiovascular system, 76–77 Career construction theory Posits
people build careers through their own actions that result from the interface of their own personal characteristics and the social context., 344, 373–374
Career plateauing Situation occurring when there is a lack of challenge in the job or promotional opportunity in the organization or when a person decides not to seek advancement., 357, 374
Caregiving adult day care, 137–139 Alzheimer’s disease, 298–299 employed caregivers, 360–361 grandparents, 337 interactions, 335f parent, 333–334 religiosity, 269 spouse/partner, 324–325 stresses and rewards, 334
Carville, James, 217 Case study An intensive
investigation of individual people., 20, 30
Casual sex, 314 Cataracts Opaque spots on the
lens of the eye, 70, 90 Causal attributions Explanations
people construct to explain their behavior, which can be situational, dispositional, or interactive., 230, 244
Cellular theories, 59–60 Center for Epidemiologic Studies-
Depression Scale (CES-D), 284
Centers for Disease Control and Prevention, 87
Cerebellum The part of the brain that is associated with motor functioning and balance equilibrium., 38, 55
Cerebral cortex The outermost part of the brain that is associated with motor functioning and balance equilibrium, 38, 55
Cerebrovascular accident (CVA) An interruption of the blood flow in the brain, 78–80, 90
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GLOSSARY/SUBJECT INDEX I-11
Cervical cancer, 110t Change, 394 Children, 329–330 chlorpromazine HCl (Thorazine®),
303 Choice goals, 345 Chronic diseases Conditions that
last a longer period of time (at least 3 months) and may be accompanied by residual functional impairment that necessitates long-term m anagement., 107–114, 125
cancer, 108–112 diabetes mellitus, 108 general issues in, 75–76 incontinence, 112–113 pain management, 113–114
Chronic obstructive pulmonary disease (COPD) A family of age-related lung diseases that block the passage of air and cause abnormalities inside the lungs., 81, 90, 103
Chronic traumatic encephalopathy (CTE), 179
Chronological age, 13–14 Cialis, 84 Climacteric The transition during
which a woman’s reproduc- tive capacity ends and ovula- tion stops., 82, 90
Clinical death Lack of heartbeat and respiration., 377, 403
Clinical studies. See Ethics Clinton, Hilary, 354 illus Cluster housing, 136 Cochlear implant, 73f Cognitive functioning, 171–172 Cognitive processes A structural
component of personality that acts jointly with life narratives to create natural interactions between a storyteller and listener, pro- cesses central in organizing life stories., 247, 273
Cognitive reappraisal task, 42f Cognitive reserve Factors that
provide flexibility in responding and adapting to changes in the environment., 171, 183
Cognitive style A trait-like pattern of behavior one uses when approaching a problem- solving situation., 234–235, 244
Cognitive therapy A type of psychotherapy aimed at altering the way people think as a cure for some forms of psychopathology, especially depression., 286, 309
Cognitive-structural approach An approach to intelligence that emphasizes the ways people conceptualize problems and
focuses on modes or styles of thinking, 189, 215
Cohabitation Living with another person as part of a committed, intimate, sexual relationship., 319–320, 340
Cohort A group of people born at the same point or specific time span in historical time., 11, 30, 195
Cohort effects One of the three basic influences examined in developmental research, along with age and time-of-measurement effects which reflects differences caused by experiences and circumstances unique to the historical time in which one lives., 20, 30
Collaborative cognition Cognitive performance that results from the interaction of two or more individuals., 238–240, 244
Collagen, 60, 62 Colonoscopy, 110t Colorectal cancer, 110t Communication enhancement
model, 149f Communication predicament, 147 Compensatory changes Changes
that allow older adults to adapt to the inevitable behavioral decline resulting from changes in specific areas of the brain., 36, 55
Competence In Lawton and Nahemow’s model, the theoretical upper limit of a person’s ability to function., 129, 156, 415–416
Complicated or prolonged grief disorder Expression of grief that is distinguished from depression and from normal grief in terms of separa- tion distress and traumatic distress., 397–398, 403
Compression of morbidity The situation in which the average age when one becomes disabled for the first time is postponed, causing the time between the onset of disability and death to be compressed into a shorter period of time., 117, 125
Computerized tomography (CT), 34
Concrete operational period, 200–201
Concussion, 178–179 Confounding Any situation in
which one cannot determine which of two or more effects is responsible for the behaviors being observed., 21, 31
Congestive heart failure A condi- tion occurring when cardiac output and the ability of the heart to contract severely decline, making the heart enlarge, increasing pressure to the veins, and making the body swell., 77–78, 91
Congregate housing, 139 Conscientiousness, 250 Continuity-discontinuity
controversy The debate over whether a particular developmental phenomenon represents smooth progres- sion over time (continuity) or a series of abrupt shifts (discontinuity)., 15–16, 31
Coping In the stress and coping paradigm, any attempt to deal with stress., 105, 125, 394
Corpus callosum A thick bundle of neurons that connects the left and right hemispheres of the cerebral cortex., 38, 55
Corrective adaptations Actions taken in response to stress- ors and can be facilitated by internal and external resources., 131, 156
Correlational study An investiga- tion in which the strength of association between variables is examined., 19–20, 31
Correspondence bias Relying more on dispositional information in explaining behavior and ignoring compelling situational infor- mation such as extenuating circumstances, 230
Correspondence bias Relying more on dispositional in formation in explain- ing behavior and ignoring compelling situational infor- mation such as extenuating circumstances., 244
Couple-forming behavior, 315 Covenant marriage, 326 Creativity, 210–211 Crestor, 421 Cross-cultural studies. See Culture;
Race and ethnicity Cross-linking Random interac-
tion between proteins that produce molecules that make the body stiffer., 60, 91
Cross-sectional study A develop- mental research design in which people of different ages and cohorts are observed at one time of measurement to obtain information about age differences., 21–22, 31
vs. longitudinal study, 24–25 CRUNCH model A model that
describes how the aging
brain adopts to neurological decline by recruiting additional neural circuits (in comparison to younger adults) to perform tasks adequately., 48, 55
Crystallized intelligence Knowledge acquired through life experience and education in a particular culture., 192, 194f, 215
Culture, 12–13 caregiving, 334 cohabitation, 320 couple-forming behavior,
315–316 death and dying, 377, 388 grandparenting, 336–337 grief processing, 392, 395,
396–397 instrumental activities of daily
living, 119 job satisfaction, 347–349 leisure activities, 365 life-span perspective, 4–5, 278 normative history-graded
influences, 12 nursing home residents, 145, 149 partner abuse, 318 romantic relationships,
315–316 suicide, 391 transracial adoption, 332 wisdom, 211 work-family conflict, 353 See also Race and ethnicity
Current controversies Alzheimer’s disease (diagnostic
criteria), 293–294 concussions, 178–179 discrimination against women,
326–327 euthanasia, 380–381 intelligence-lifestyle effects, 196 intraindividual change/stability
of traits, 251–252 long-term care financing,
142–143 marriage education, 326–327 menopausal hormone therapy,
83–84 neural stem cells, 51 personality in youth/personality
in old age, 15 prostate cancer, 111–112 Social Security and Medicare,
413–414 stereotypes-cognitive
performance, 221–222
Dalai Lama, 186 Dating, 314–316 Death and dying, 375–402
bereavement, 392 clinical death, 377 complicated or prolonged grief
disorder, 397–398 contextual theory of, 385
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I-12 GLOSSARY/SUBJECT INDEX
dealing with one’s own death, 384–385
death anxiety, 385–387 death of child, 399 death of parent, 399–400 definitions, 376–378 end-of-life issues, 387–392 ethical issues, 378–382 euthanasia, 379–380 famous people (tragic), 376 illus final scenario, 388, 403 grieving process, 392–400 hospice, 388–390 Kübler-Ross’s theory, 384–385 legal and medical definitions,
377–378 life-course approach to dying,
383–384 life-sustaining care, 382–383 living will, 390 mourning, 392 palliative care, 388 patient self-determination and
competency evaluation, 390–392
physician-assisted suicide, 381–382
separation distress, 398 sociocultural definitions, 376–377 terror management theory,
385–386 traumatic distress, 398 whole-brain death, 377–378
Death anxiety People’s anxiety or even fear of death and dying., 385–387, 403
Death with Dignity Act, 381 Decision making, 206–207 Default network of the brain The
regions of the brain that are most active at rest., 48, 55
Delirium A disorder characterized by a disturbance of consciousness and a change in cognition that develop over a short period of time., 287, 309
Delusion, 303 Dementia A family of diseases
characterized by cognitive decline. Alzheimer’s disease is the most common form., 287–301, 309
AIDS dementia complex, 300–301
alcohol-related, 300 Alzheimer’s disease, 289–299 famous people, 275 Huntington’s disease, 300 Parkinson’s disease, 299–300 patient care, 298–299 social policy implications, 305–306 training persons with, 297–298 vascular dementia, 299
Demographic trends, 407–409 Dendrites A structural feature
of the neuron that acts like antennas to receive signals
from other nearby neurons., 37, 55
Density of Representations Yields Age-related Deficits (DRYAD) model, 171
Dependency ratio The ratio of the number of people under age 15 and over age 64 in a country to the number of people between 15 and 65, 407, 425
Dependent care, 360–361 Dependent life expectancy The
age to which one can expect to live with assistance, 95, 125
Dependent variable Behaviors or outcomes measured in an experiment., 19, 31
Depression, 282–287 assessment scales, 284 causes, 284–285 characteristics, 283–284 prevalence, 282f symptoms, 283–284 treatment, 285–287, 288t
Developmental coach, 346–347 Diabetes mellitus A disease that
occurs when the pancreas produces insufficient insulin., 70, 109, 125
Diabetic neuropathy, 70 Dialectical thinking, 203 Dietary Guidelines for Americans
2010, 420 Differential reinforcement of
incompatible behavior (DRI), 296–297
Diffusion tension imaging (DTI) The measurement of the diffusion of water molecules in tissue in order to study connections of neural path- ways in the brain., 40, 55
Disability The effects of chronic conditions on people’s ability to engage in activities that are necessary, expected, and personally desired in their society., 117–119, 125
causes of, 120–121 model, 117–119
Discrimination, 353–356 Disease prevention, 416–421 Disease-modifying anti-rheumatic
drugs (DMARDs), 66 Dispositional attribution An
explanation for someone’s behavior that resides within the behavior., 230, 231f, 244
Dispositional trait A relatively stable, enduring aspect of personality., 247, 250–252, 273
Diversity. See Culture; Race and ethnicity
Divided attention The ability to pay attention and successfully
perform more than one task at a time., 161, 183
Divorce, 325–327 divorce rates, world, 325f effects, 327 reasons for, 325–326 who gets divorced, 325–326
Dizziness, 74 Do Not Resuscitate (DNR) order
A medical order that means cardiopulmonary resuscita- tion (CPR) is not started should one’s heart and breathing stop., 390, 403
Docility When people allow the situation to dictate the options they have and exert little control., 130, 156
Docosahexaenoic acid (DHA), 52 Donepezil, 295 Dopamine A neurotransmitter
associated with higher-level cognitive functioning., 39, 55, 299
Dopaminergic system Neuronal systems that use dopamine as their major neurotrans- mitter., 39, 55
Drug excretion The process of eliminating medications, usually through the kidneys in urine, but also through sweat, feces, and saliva., 115, 125
Drug metabolism The process of getting rid of medications in the bloodstream, partly in the liver., 115, 125
Dual-process model (DPM) View of coping with bereavement that integrates loss-oriented stressors and restoration- oriented stressors., 397, 403
Dysphoria Feeling down or blue, marked by extreme sad- ness; the major symptom of depression., 283, 309
Echo Boomers, 12 Ecology of aging Also called
environmental psychology, a field of study that seeks to understand the dynamic relations between older adults and the environments they inhabit., 134–135, 156
Eden Alternative, 152 Effortful processing It requires all
of the available attentional capacity when processing information., 162, 183
Ego development The fundamen- tal changes in the ways in which our thoughts, values, morals, and goals are orga- nized. Transitions from one stage to another depend on both internal biological
changes and external social changes to which the person must adapt., 273
Eicosapentaenoic acid (EPA), 52 Elder abuse, 318 Elder abuse prevention, 337–338 Elderspeak, 147, 148 Electroconvulsive therapy, 286 Electroencephalogram (EEG), 281 Emerging adulthood A period
when individuals are not adolescents but are not yet fully adults., 14, 31
Emotion and logic, 203–204 as processing goal, 233–234 and structural changes in brain,
41–44 well-being, 264–265
Emotional abuse, 318 Emotion-focused coping A style
of coping that involves dealing with one’s feelings about the stressful event, 105, 125
Emphysema Severe lung disease that greatly reduces the ability to exchange carbon dioxide for oxygen., 81, 91
Employment. See Work Encoding The process of getting
information into the memory system, 165, 183
End-of-life issues Issues pertain- ing to the management of the final phase of life, after-death disposition of their body, memorial services, and dis- tribution of assets., 387, 403
Environmental press In Lawton and Nahemow’s model, the demands put on a person by the environment., 129, 156
Epigenetic principle In Erikson’s theory, the notion that development is guided by an underlying plan in which certain issues have their own particular times of impor- tance., 254, 273
Epilepsy, 65, 178 Episodic memory The general
class of memory having to do with the conscious recollection of information from a specific event or point in time., 164–166, 172, 183
Erectile dysfunction, 84 Erikson’s stages of personality
development, 254–257 Ethics
bioethics, 378–379 elderspeak, 148 negative life events, 106 neural stem cell research, 51 in research, 24, 26–27 Tai Chi approach, 74
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GLOSSARY/SUBJECT INDEX I-13
Ethnic differences. See Race and ethnicity
Ethnicity. See Race and ethnicity Euthanasia The practice of ending
life for reasons of mercy., 379–380, 403
Everyday competence A person’s potential ability to perform a wide range of activities considered essential for independent living., 133–134, 156
Exacerbators Situations that makes a situation worse than it was originally., 119, 126
Exchange theory A theory of rela- tionships based on the idea that each partner contributes something to the relationship that the other would be hard- pressed to provide., 322, 340
Executive functions Include the ability to make and carry out plans, switch between tasks, and maintain attention and focus., 38, 40, 55
Exelon® (rivastigmine), 295 Exercise, 171
aerobic, 418–419 and brain aging, 51–52
Experiment A study in which participants are randomly assigned to experimental and control groups and in which an independent variable is manipulated to observe its effects on a dependent vari- able so that cause-and-effect relations can be established., 19, 31
Experimental design, 19 Expertise, 209–210 Explicit memory The conscious
and intentional recollection of information., 164, 183
Extended family, 329 External aids Memory aids that
rely on environmental resources., 174–175, 183
Extraversion, 249 Eyes, 69–70
Factor The interrelations among performances on similar tests of psychometric intelligence., 191, 215
Falls, 74, 87 False memory When one remem-
bers items or events that did not occur., 171, 183
Familism Refers to the idea that the well-being of the family takes precedence over the concerns of individual family members., 331, 340
Family children, 329–330 extended, 329
household chores, 361–362 nuclear, 329 and work, 360–363 work-family conflict, 362–363 See also Parenthood
Female reproductive system, 82–83 Filial obligation The feeling that,
as an adult child, one must care for one’s parents., 333, 340
Final scenario Making one’s choices known about how they do and do not want their lives to end., 388, 403
Financial exploitation, 318 Five-factor model A model of
dispositional traits with the dimensions of neu- roticism, extraversion, openness to experience, agreeableness-antagonism, and conscientiousness- undirectedness., 248–250, 273
Flashbulb memories Memories for personally traumatic or unexpected events, 169, 184
Fluid intelligence Abilities that make one a flexible and adaptive thinker, that allow one to draw inferences, and that allow one to understand the relations among concepts independent of acquired knowledge and experience., 192, 194f, 215
Forces of development, 11 Foreman, George, 58 Formal operational period, 201 Foster parents, 331–332 Four-component model Model of
grief that understanding grief is based on (1) the context of the loss; (2) continuation of subjective meaning associ- ated with loss; (3) changing representations of the lost relationship over time; and (4) the, 395–396, 404
Fox, Michael J., 299 Frail older adults Older
adults who have physical disabilities, are very ill, and may have cognitive or psychological disorders and need assistance with everyday tasks., 119, 126
Free radicals Substances that can damage cells, including brain cells, and play a role in can- cer and other diseases as we grow older, (ii) Deleterious and short-lived chemicals that cause changes in cells that are thought to result in aging, 33, 55, 60, 91
Friendships, 311–313 ABCDE stages of, 312 adulthood, 313–314
affective/emotional, 312 cross-sex, 313 men’s, 313 shared/communal, 312 sociability/compatibility, 312 socioemotional selectivity, 313 women’s, 313 See also Relationships
Functional health status How well a person is functioning in daily life, 119, 126
Functional incontinence A type of incontinence usually caused when the urinary tract is intact but due to physical, 112, 126
Functional magnetic resonance imaging (fMRI), 34
Functional neuroimaging Provides an indication of brain activity but not high anatomical detail., 34, 55
Galantamine, 295 Gay and lesbian couples,
320–321, 332 Gender
alcohol abuse, 304 anxiety disorders, 301 bias and discrimination, 353–356 bone loss, 64 chronological age, 13 grief, 393–394 hearing loss, 72f incontinence, 112 Jung’s theory, 253–254 longevity, 95f, 97 mental health, 278–279 nursing home residents, 141 occupational development,
352–353 occupational selection, 351–352 older couples, 324 retirement, 368 single parents, 331 stress response, 103
Gender discrimination Denying a job to someone solely on the basis of whether the person is a man or a woman., 353, 374
Generation X, 12, 407 Generation Y, 12 Generativity, 257–258 Geriatric Depression Scale, 284 Gerontology The study of aging
from maturity through old age., 3, 31
Gibran, Khalil, 344 Glass ceiling The level to which a
woman may rise in an orga- nization but beyond which they may not go., 374
Glass cliff A situation in which a woman’s leadership position in an organization is precari- ous., 354, 374
Glaucoma A condition in the eye caused by abnormal drainage of fluid., 70, 91
Goals, 232–235 cognitive style as, 234–235 emotion as, 233–234 personal, 233
Grandchildren, 335–337 Grandparenthood, 335–337 Grandparenting styles, 336–337 Green House Project, 152 Grief, 392–393
adult developmental aspects of, 398–400
anniversary reaction, 395 anticipatory, 394 complicated or prolonged grief
disorder, 397–398 coping with, 395–397 dual process model, 397 four-component model,
395–396 normal grief reactions, 394–395 processing and avoidance,
396–397 risk factors, 393–394 separation distress, 398 traumatic distress, 398 See also Death and dying
Grief The sorrow, hurt, anger, guilt, confusion, and other feelings that arise after suf- fering a loss., 404
Grief work as rumination hypothesis An approach that not only rejects the necessity of grief processing for recovery from loss but views extensive grief processing as a form of rumination that may actually increase distress., 394, 396, 404
Grief work The psychological side of coming to terms with bereavement., 404
Grieving process, 392–400
Hair, 62–63 haloperidol (Haldol®), 303 HAROLD model A model that
explains the empirical find- ings of reduced lateralization in prefrontal lobe activity in older adults (that is, the reduced ability of older adults to separate cognitive process- ing in different parts of the prefrontal cortex), 47–48, 55
Hayflick, Leonard, 59 Hayflick limit, 59 Health care power of attorney
A document in which an individual appoints someone to act as his or her agent for health care decisions., 390, 391f, 404
Health promotion, 414–415 disease prevention, 416–421 lifestyle factors, 418–421 nutrition, 420–421
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I-14 GLOSSARY/SUBJECT INDEX
Health The absence of acute and chronic physical or mental disease and impairments., 99, 126
functional, 119–120 immune system, 100–102 intelligence, 197 quality of life, 100 stress effects, 107
Healthy Marriage Initiative, 326 Hearing, 71–73 Hearing aids, 73f Hearing Education and Awareness
for Rockers (HEAR), 71 Hearing loss, 71–73
gender differences, 72f helping people with, 73f
Heart, 76, 77f Heart attack, 77, 78, 82, 83, 299 Hemiplegia, 79 High-density lipoproteins (HDLs)
Help keep arteries clear and break down LDLs., 421, 426
Hippocampus Located in the medial-temporal lobe, this part of the brain plays a major role in memory and learning., 38, 55
structural changes in brain, 41 HIV infection, 102, 300–301 Home modification, 137 Homogamy The notion that
similar interests and values are important in forming strong, lasting interpersonal relationships., 314, 321, 340
Hookups, 315 Hospice An approach to assisting
dying people that empha- sizes pain management, or palliative care, and death with dignity., 388–390, 404
Household chores, 361–362 Houston, Whitney, 376 Human Genome Project, 96 Huntington’s disease, 300 Hypertension A disease in which
one’s blood pressure is too high., 80, 91
Hypotension, 80
Illness The presence of a physical or mental disease or impairment., 99, 126
acute diseases, 103 chronic conditions, 107–113 depression, 285t disease prevention, 416–421 pain management, 113–114
Immune system, 100–102 Immunizing mechanisms Control
strategies that alter the effects of self-discrepant evidence., 236, 244
Immunoglobulins, 101 Implicit memory The effortless
and unconscious recollection of information., 164, 184
Implicit stereotyping Stereotyped beliefs that affect your judg- ments of individuals without your being aware of it (i.e., the process is unconscious)., 220–221, 244
Impression formation The way in which people combine the components of another person’s personality and come up with an integrated perception of the person., 226–228, 244
Incontinence The loss of ability to control the elimination of urine and feces on an occa- sional or consistent basis, 112–113, 126, 296
Independent variable The variable manipulated in an experi- ment., 19, 31
Inductive reasoning, 24f, 25f, 191 Infantilization or elderspeak Also
called secondary baby talk, a type of speech that involves the unwarranted use of a person’s first name, terms of endearment simplified expressions, short impera- tives, an assumption that the recipient has no memory, and cajoling as a means of demanding compliance., 147, 156
Information-processing model The study of how people take in stimuli from their environment and transform them into memories; the approach is based on a com- puter metaphor., 159–160, 184
Inhibitory loss, 161 Instrumental activities of daily
living (IADLs) Actions that entail some intellectual competence and planning., 119–120, 126
Intellectual change, 195–197 Intelligence, 187–198
cognitive-structural approach, 189
crystallized, 192, 194f in everyday life, 187 fluid, 192, 194f health, 197 information processing, 195–196 intellectual change, 195–197 measurement, 190–191 mechanics, 188, 189f Parieto-Frontal Integration
theory, 46 personality, 197 Piaget’s theory, 200–201 pragmatic, 188, 189f psychometric approach, 189 social and life style variables, 196 structure, 191
Interindividual variability An acknowledgment that adults differ in the direction of their intellectual development., 188, 215
Internal aids Memory aids that rely on mental processes., 174–176, 184
Jackson, Michael, 376 Job satisfaction The positive
feeling that results from an appraisal of one’ work., 347–349, 374
Joints, 66–67 Jung’s theory, 253–254
Kegan’s theory of self-concept, 264 Kinkeeper The person who
gathers family members together for celebrations and keeps them in touch with each other., 332, 340
Kinship, 104, 394 Kübler-Ross’s theory of death and
dying, 384–385 !Kung tribe, 16
La Rochefouçauld, Francois de, 376
Labeling theory Argues that when we confront an age-related stereotype, older adults are more likely to integrate it into their self-perception, 225, 244
Labouvie-Vief’s dynamic integration theory, 264
Latino Americans alcohol abuse, 304 division of household labor,
362, 363 grandparents, 336 grief, 395 HIV, 102 menopause, 82 nursing home residents, 143 occupational development, 353 older adults (in U.S.), 7 single parents, 331 women in labor force, 351 women’s earnings as a percent of
men’s in 2010, 355f See also Culture; Race and
ethnicity Lean In: Women, Work, and the
Will to Lead (Sandberg), 354 Learning, lifelong, 210 Ledger, Heath, 376 Leisure A discretionary activity
that includes simple relax- ation, activities for enjoy- ment, and creative pursuits., 374
Leisure activities, 363–366 consequences, 365–366 developmental changes, 364–365 types of, 364
Lesbian couples, 320–321, 332 Levodopa, 300 Life course approach to dying,
383–384 Life narrative The aspects
of personality that pull everything together, those integrative aspects that give a person an identity or sense of self., 247, 273
Life stories, 261, 270 Life transitions, 258 Life-cycle forces One of the four
basic forces of development that reflects differences in how the same event or combination of biological, psychological, and sociocul- tural forces affects people at different points in their lives., 11, 31
Lifelong learning, 210 Life-span construct In
Whitbourne’s theory of identity, the way in which people build a view of who they are., 262, 273
Life-span perspective A view of the human life-span that divides it into two phases: childhood adolescence and young/middle/late adulthood., 4–5, 31, 415–416
Lifestyle disease prevention, 418–421 health promotion, 418–421 love relationships, 318–328
Life-sustaining care, 382–383 Limbic system A set of brain
structures involved with emotion, motivation, and long-term memory, among other functions, 38, 55
Lipitor, 421 Lipoproteins, 421 Lithium, 286 Living will A document in which
a person states his or her wishes about life support and other treatments., 390, 404
Logic, 203–204 Longevity, 93–98
average, 94 environmental factors, 96 ethnic differences, 96–97 gender differences, 95f, 97 genetic factors, 95–96 international differences, 98 maximum, 94–95
Longitudinal study A develop- mental research design that measures one cohort over two or more times of measurement to examine age changes., 22–23, 31
vs. cross-sectional study, 24–25 Long-term care, financing,
142–143
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GLOSSARY/SUBJECT INDEX I-15
Long-term memory The aspects of memory involved in remem- bering rather extensive amounts of information over relatively long periods of time., 164–166, 184
Lorayne, Harry, 158 Loss-oriented stressors, 397 Love, 313–316
assortative mating, 314–316 falling in, 314 lifestyles, 318–328 through adulthood, 314 See also Relationships
Low-density lipoproteins (LDLs) Cause fatty deposits to accumulate in arteries, imped- ing blood flow., 421, 426
Lung cancer, 110t
Magnetic resonance imaging (MRI), 34
Male reproductive system, 83–84 Marital adjustment The degree
spouses accommodate each other over a certain period of time, 321, 340
Marital quality The subjective evaluation of the couple’s relationship on a number of different dimensions,, 321, 341
Marital satisfaction A global assessment of one’s marriage, 321, 341
Marital success An umbrella term referring to any marital outcome, 321, 341
Marriage, 321–325 age, 321f caring for spouse/partner,
324–325 covenant, 326 early years, 323 exchange theory, 322 midlife, 324 older couples, 324 remarriage, 327–328 satisfaction level, 322–323 success factors, 321–322 See also Relationships
Marriage education An approach based on the idea the more couples are prepared for marriage, the better the relationships will survive over the long run., 326–327, 341
Married singles Married couples who have grown apart but continue to live together., 324, 341
Matalin, Mary, 217 Mate selection, 314–316 Material exploitation, 318 Maximum longevity The maxi-
mum length of time an organism can live - roughly
120 years for human., 94–95, 126
McAdams’s life-story model, 261–262
Whitbourne’s identity theory, 262–263
McAdams’s model of generativity, 257–258
McCain, John, 2, 3f Meaning-mission fit Alignment
between people’s personal intentions and their com- pany’s mission., 344, 374
Measurement, 17–19 Mechanics of intelligence The
aspect of intelligence that concerns the neurophysi- ological architecture of the mind, 188, 215
Medicare, 120f, 142f, 410, 412–414 Medication, 114–116
adherence to regimens, 116 developmental changes, 114–115 side effects and interactions,
115–116 use patterns, 114
Memantine, 295 Memory, 163–180
autobiographical, 169–170 drugs, 177 encoding, 163 episodic, 164–166, 172 exercise, 171 explicit, 164 external aids, 174–175 false, 171 flashbulb, 169 implicit, 164 internal aids, 174–176 long-term, 164–166 mental health, 178 metamemory, 173 monitoring, 173–174 negative stereotype, 172 normal vs. abnormal aging,
177–178 nutrition, 179–180 physical health, 178 prospective, 167–168 recall, 165 recognition, 165 rehearsal, 163 retrieval, 163, 166 self-efficacy, 173 self-evaluation, 172–173 semantic, 164–165, 172 sensory, 160 social context, 240 source, 170–171 storage, 163 and structural changes in brain, 41 testing, 177 training, 174–176 working, 163–164
Menopausal hormone therapy (MHT) Low doses of estro- gen, which is often combined with progestin (synthetic form
of progesterone) taken to counter the effects of declin- ing estrogen levels., 82–83, 91
Menopause The cessation of the release of eggs by the ovaries., 82, 91
Mental health, 276 anxiety disorders, 301–302 assessment methods, 281 delirium, 287 dementia, 287–301 depression, 282–287 developmental issues in therapy,
281–282 ethnicity, 278–279 gender difference, 278–279 multidimensional assessment,
279–280 psychotic disorders, 302–304 substance abuse, 304
Mental status exam A short screening test that assesses mental competence, usually used as a brief indicator of dementia or other serious cognitive impairment., 279, 309
Mentor or developmental coach A person who is part teacher, sponsor, model, and coun- selor who facilitates on-the- job learning to help a new hire do the work required in his or her present role and to prepare for future roles., 346, 374
Mercy killing, 376, 379 Meta-analysis A technique that
allows researchers to syn- thesize the results of many studies to estimate relations between variables., 26, 31
Metabolism How much energy the body needs., 420, 426
Metamemory Memory about how memory works and what one believes to be true about it., 173, 184
Microgenetic study A special type of longitudinal design in which participants are tested repeatedly over a span of days or weeks typically with the aim of observing change directly as it occurs., 22, 31
Middle-aged adults care providers, 334, 335f children of, 332–333 parents of, 333–334
Midlife correction Reevaluating one’s roles and dreams and making the necessary corrections., 259, 273
Midlife crisis, 258–259 Millenials, 12, 346, 407 Million Women Study, 83 Mobility, 63
Monoamine oxidase (MAO) inhibitors, 286
Monocytes, 101 Motivation, 232–235 Mourning The ways in which we
express our grief., 392, 404 Multidimensional The notion that
intelligence consists of many dimensions., 187, 215
Multidirectionality The distinct patterns of change in abilities over the life span, with these patterns being different for different abilities., 4, 188, 215, 235–236
Multilingualism, 171–172 Multiple causation, 4 Muscles, 63–64 Myocardial infarction (MI) A
heart attack., 78, 91
Namenda® (memantine), 295 Narrative, 394 Native Americans
alcohol abuse, 304 grandparents, 336–337 older adults (in U.S.), 7 parenting, 330 See also Race and ethnicity
Natural killer (NK) cells, 101 Nature-nurture issue A debate
over the relative influence of genetics and the environ- ment on development., 14–15, 31
Near infrared spectroscopic imaging (NIRSI), 34
Negativity bias Weighing negative information more heavily than positive information in a social judgment., 228, 244
Neglect, 318 Neural efficiency hypothesis
States intelligent people process information more efficiently, showing weaker neural activations in a smaller number of areas than less intelligent people., 195–197, 215
Neural stem cells Cells that persist in the adult brain and can gen- erate new neurons throughout the life span, 50, 55
Neuro correlational approach An approach that attempts to relate measures of cognitive performance to measures of brain structure or function- ing, 36, 55
Neuroanatomy The study of the structure of the brain, 38, 55
Neurofibers Structures in the neuron that carry information inside the neu- ron from the dendrites to the terminal branches, 37, 55
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I-16 GLOSSARY/SUBJECT INDEX
Neuroimaging A set of techniques in which pictures of the brain are take in various ways to provide understand- ing of both normal and abnormal cognitive aging, 34, 55
functional, 34 structural, 34
Neurons A brain cell, 37, 55 age-related changes in, 38–39
Neuropsychological approach Compares brain functioning of healthy older adults with adults displaying various pathological disorders in the brain., 35, 55
Neuroscience The study of the brain., 33, 55, 166–167
Neuroticism, 248–249 Neurotransmitters Chemicals that
carry information signals between neurons across the synapse., 37, 56
age-related changes in, 39 Nonnormative influences
Random events that are important to an individual but do not happen to most people., 12, 31
Norepinephrine and dopamine reuptake inhibitors (NDRIs), 285
Normative age-graded influences Experiences caused by bio- logical, psychological, and sociocultural forces that are closely related to a person’s age., 11–12, 31
Normative history-graded influences Events that most people in a specific culture experience at the same time., 12, 31
Nuclear family, 329 Number, 24f, 25f, 191 Nursing homes, 141–153
characteristics, 144–145 communication with residents,
147–150, 149f decision-making, 150–151 vs. home, 146–147 individual choices, 150–151 new directions, 152–153 resident satisfaction, 147f special care units, 145–146 types, 141–142 typical residents, 143–144
Nutrition, 420–421 and brain aging, 52 memory and, 179–180
Nyad, Diana, 2
Obama, Barack, 311 Obama, Michelle, 311 Obesity, 421t Observed Tasks of Daily Living
(OTDL), 208
Occupational choice, 344–345 Occupational development,
345–347, 352–353 Occupational expectations,
345–346 Occupational insecurity, 357–358 Occupational selection, 351–352 Occupational transition, 356–359
occupational insecurity, 357–358 retraining workers, 357 unemployment, 358–359
Older Americans Act, 410, 417 Older couples, 324 Omega-3 fatty acids, 52 Oncale v. Sundowner Offshore
Services, 356 Online dating, 314 Openness to experience, 249 Optimally exercised ability The
ability a normal, healthy adult would demonstrate under the best conditions of training or practice., 208, 215
Osteoarthritis A form of arthritis marked by gradual onset and progression of pain and swelling, caused primarily by overuse of a joint., 66, 67f, 68t, 91
Osteoporosis A degenerative bone disease more common in women in which bone tissue deteriorates severely to pro- duce honeycomb-like bone tissue., 64–66, 68t, 91
Outcome expectations, 345 Overflow incontinence A type of
incontinence usually caused by improper contraction of the kidneys, causing the bladder to become overdistended., 112, 126
Overweight, 421t
Pain, 113–114 Palliative care Care that is focused
on providing relief from pain and other symptoms of disease at any point during the disease process., 388, 404
Paranoid disorders, 303 Paranoid-type schizophrenia, 303 Parenthood, 329–332
adoptive parents, 331–332 adult children, 332–333, 333 illus death of parent, 399–400 ethnic diversity, 330–331 foster parents, 331–332 grandparenthood, 335–337 same-sex parents, 332 single parents, 331 stepparents, 331–332 See also Family
Parieto-Frontal Integration theory (P-FIT) A theory that proposes that intelligence comes from a distributed
and integrated network of neurons in the parietal and frontal areas of the brain., 46, 56
Parkinson’s disease, 299–300 Parks, Rosa, 275 Passion A strong inclination
toward an activity that individuals like (or even love), that they value (and thus find important), and in which they invest time and energy., 374
Passive euthanasia Allowing a person to die by withholding available treatment., 379, 404
Patient Self-Determination Act, 390
Patronizing speech Inappropriate speech to older adults that is based on stereotypes of incompetence and depen- dence., 147, 156, 349–350
Perceived age, 14 Perimenopause The time of
transition from regular menstruation to menopause., 82, 91
Persistent vegetative state Situation in which a person’s cortical functioning ceases while brainstem activity continues., 378, 404
Personal concerns Things that are important to people, their goals, and their major concerns in life., 247, 252–253, 273
Personal control The belief that what one does has an influence on the outcome of an event., 235–238, 244
multidimensionality, 235–236 strategies, 236–237
Personal goals, 233 Personality, 197, 245–272
adjustment, 250, 273 alcohol-related dementia, 300 death anxiety, 385–387 delirium, 287 dispositional traits, 247–252 divorce, 326 Erikson’s stages of personality
development, 254–257 five-factor model, 248–250 growth, 250, 273 Hungtington’s disease, 300 internal memory aids, 174–176 Jung’s theory, 253–254 Labouvie-Vief’s dynamic
integration theory, 264 life narrative, 247 McAdams’s life-story model,
261–262 McAdams’s model of
generativity, 257–258 nature-nurture issue, 14–15
occupational choice, 344–345 personal concerns, 252–253 primary control, 237–238 psychological forces, 11 psychotic disorders, 302–304 quality of life, 100 self-concept, 264 social policy implications, 270 sociocultural age, 14 well-being, 264–265
Person-environment interactions The interface between people and the world in which they live that forms the basis for development, meaning that behavior is a function of both the person and the environment., 128–129, 156
behavioral and emotional out- comes, 129f
competence, 129–131 environmental press, 129–131 everyday competence, 133–134 preventive and corrective
proactivity model, 131–132 stress and coping framework,
132–133 Phelps, Michael, 58 Physical abuse, 318 Physical activity. See Exercise Physical changes, 57–90
appearance and mobility, 61–68 autonomic nervous system,
84–86 balance, 73–74 biological theories, 58–59 body build, 63 bones, 64–66 cardiovascular system, 76–80 cellular theories, 59–60 developmental forces, 60–61 hair, 62–63 hearing, 71–73 joints, 66–67 muscles, 63–64 programmed-cell-death
theories, 60 rate-of-living theories, 59 reproductive system, 81–84 respiratory system, 80–81 sensory systems, 69–76 skin, 62 smell, 75–76 social policy implications, 87 somesthesia, 73 taste, 75 vision, 69–71 vital functions, 76–81 voice, 63
Physician-assisted suicide Process in which physicians provide dying patients with a fatal dose of medication the patient self-administers., 381–382, 404
Piaget’s theory, 200–201 Pioneer Network, 152–153
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GLOSSARY/SUBJECT INDEX I-17
Plasticity The belief that capac- ity is not fixed, but can be learned or improved with practice, (ii) Involves the interaction between the brain and the environment and is mostly used to describe the effects of experience on the structure and functions of the neural system, (iii) The range of functioning within an individual and the condi- tions under which a person’s abilities can be modified within a specific age range., 4, 16, 31, 50, 56, 188, 215
Pocket Smell Test, 75 Policy implications. See Social
policy implications Polymorphonuclear neutrophil
leukocytes, 101 Polypharmacy The use of multiple
medications., 115, 126 Population trends, 5–10 Positivity effect When an
individual remembers more positive information rela- tive to negative information (ii) The tendency to attend to and process positive information over negative information, 45, 56, 234, 244
Positron emission tomography (PET), 34
Possible selves Aspects of the self-concept involving oneself in the future in both positive and negative ways., 268, 273
Post-formal thought Thinking characterized by a recogni- tion that truth varies across situations, that solutions must be realistic to be rea- sonable, that ambiguity and contradiction are the rule rather than the exception, and that emotion and the exception, and that emotion and subjective factors play a role in thinking., 202, 215
Poverty rates, 409f Pragmatic intelligence The com-
ponent of intelligence that concerns acquired bodies of knowledge., 188, 215
Prefrontal cortex (PFC) Part of the frontal lobe that is involved in executive functioning., 38, 44–45, 56
Preoperational period, 200 Presbycusis A normative
age-related loss of the ability to hear high-pitched tones., 71, 91
Presbyopia The normative age-related loss of the ability to focus on nearby objects,
usually resulting in the need for glasses., 69, 91
Preventive adaptations Actions that avoid stressors and increase or build social resources., 131, 156
Preventive and corrective proactivity model, 131–132
Primary aging Normal, disease-free development during adulthood., 13–14, 31
Primary appraisal First step in the stress and coping paradigm in which events are categorized into three groups based on the significance they have for our well-being - irrelevant, benign, or positive, and stressful., 104, 126
Primary control The act of bringing the environment into line with one’s own desires and goals, similar to Brandtstädter’s accommoda- tive activities., 237–238, 244
Primary mental abilities Independent abilities within psychometric intelligence based on different com- binations of standardized intelligence tests., 191, 197–198, 215
Primary prevention Any interven- tion that prevents a disease or condition from occurring., 417, 426
Proactivity When people choose new behaviors to meet new desires or needs and exert control over their lives., 130, 156
Problem solving, 207–209 Problem-focused coping A style
of coping that attempts to tackle a problem head-on., 105, 126
Processing resources The amount of attention one has to apply to a particular situation, 161, 184
Programmed-cell-death theories, 60 Project ACTIVE, 198 Prophet, The (Gibran), 344 Prospective memory Process
involving remembering to remember something in the future., 167–168, 184
Prostate cancer, 110t–111t, 111–112
Psychological abuse, 318 Psychological age, 14 Psychological forces One of
the four basic forces of development that includes all internal perceptual, cognitive, emotional, and personality factors., 11, 31
Psychometric approach An approach to intelligence involving defining it as performance on standard- ized tests., 189, 215
Psychoneuroimmunology The study of the relations between psychological, neurological, and immuno- logical systems that raise or lower our susceptibility to and ability to recover from disease., 102, 126
Psychopathology, 276–278 biological forces, 277 life-cycle factors, 278 life-span approach, 277–278 psychological forces, 277 sociocultural forces, 278
Psychotherapy, 302 illus Psychotic disorders, 302–304
Quality of life A person’s well-being and life satisfac- tion., 100, 414–415, 426
“Quasi-reflective” thinking, 202 Quaternary prevention Efforts
specifically aimed at improving the functional capacities of people who have chronic conditions., 418, 426
Race and ethnicity, 12–13 activities of daily living, 120 adopted children, 332 alcohol abuse, 304 cardiovascular disease, 77 caring for spouse/partner, 325 cerebrovascular accident, 79 depression, 276, 278, 283 division of household labor,
362, 363 divorce, 325 ethnic identity, 12 familism, 331 gay and lesbian couples, 320 glass ceiling, 337 grandparents, 336–337 grief, 395 HIV, 102 hypertension, 80 life expectancy, 96–97 longevity, 96–97 menopause, 82 mental health, 278–279 nursing home residents, 143, 146 occupational development, 353 occupational expectations, 346 older adults (in U.S.), 7 parenthood, 330–331 religiosity, 268, 269 remarriage, 327 retirement, 368 self-rated health, 97 single parents, 331 singlehood, 319 urinary incontinence, 112 v. culture, 12–13
wage gap, 355 women in labor force, 351 women’s earnings as a percent of
men’s in 2010, 355f See also Culture
Rate-of-living theories, 59 Razadyne® (galantamine), 295 Reagan, Ronald, 275 Reality shock Situation in which
what you learn in the classroom does not always transfer directly into the “real world” and does not represent all you need to know., 346, 374
Reappraisal In the stress and coping paradigm, this step involves making a new primary or secondary appraisal resulting from changes in the situation., 104–105, 126
Reappraisal task, 42f Recall Process of remembering
information without the help of hints or cues., 165, 184
Recognition Process of remember- ing information by selecting previously learned informa- tion from among several items., 165, 184
Reflective judgment Thinking that involves how people reason through dilemmas involving current affairs, religion, science, and the like., 202–203, 215
Rehearsal Process by which information is held in working memory, either by repeating items over and over or by making meaning- ful connections between the information in working memory and information already known., 163, 184
Relationships, 310–339 abusive, 316 caring for parent, 333–334 caring for spouse/partner, 324–325 cohabitation, 319–320 divorce, 325–327 friendships, 311–313 gay and lesbian couples, 320–321 grandparenthood, 335–337 love, 313–316 marriage, 321–325 mate selection, 314–316 remarriage, 327–328 singlehood, 319 violence in, 316–318 widowhood, 328
Relativistic thinking, 203 Reliability The ability of a
measure to produce the same value when used repeatedly to measure the identical phe- nomenon over time., 17, 31
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I-18 GLOSSARY/SUBJECT INDEX
Religiosity, 268–269 Remarriage, 327–328 Reproductive system, 81–84 Research designs, 19–20
case study, 20 correlational design, 19–20 cross-sectional designs, 21–22 experimental design, 19 longitudinal designs, 22–23 sequential designs, 23–26
Resilience theory Argues that confronting a negative stereotype results in a rejection of that view in favor or a more positive self-perception, 225, 244
Respiratory diseases, 81 Respiratory system, 80–81 Restoration-oriented stressors, 397 Retina, 70 Retirement, 366–370
adjustment to, 368 defined, 366–367 ethnic differences, 368 gender difference, 368 reasons for, 367–368 volunteering, 370 working in late life, 369–370
Retrieval The process of getting information back out of memory, 163, 166, 184
Rheumatoid arthritis A destruc- tive form of arthritis involv- ing more swelling and more joints than osteoarthritis., 66, 67f, 68t, 91
Risk factors Long-standing behaviors or conditions that increase one’s chances of functional limitation or disability., 118, 126
Rivastigmine, 295 Romantic relationships, cultural
differences in, 315–316
Salary discrimination, 355 Same-sex parents, 332 Sampling, 18–19 Sanchi (Chinese herb), 61 Sandberg, Sheryl, 354 Sandwich generation Middle-aged
adults caught between the competing demands of two generations: their parents and their children., 332, 341
Scaffolding Theory of Cognitive Aging (STAC) A model based on the idea that age-related changes in one’s ability to function reflect a life-long process of compen- sating for cognitive decline by recruiting additional brain areas., 48–50, 56
Schiavo, Terri, 380–381 Schizophrenia, 39, 303–304 Secondary aging Developmental
changes that are related to
disease, lifestyle, and other environmental changes that are not inevitable., 13, 31
Secondary appraisal In the stress and coping paradigm, an assessment of our perceived ability to cope with harm, threat, or challenge., 104, 126
Secondary control The act of bringing oneself in line with the environment, similar to Brandtstädter’s accommoda- tive activities, 237, 244
Secondary mental abilities Broad-ranging skills composed of several primary mental abilities., 191, 193, 215
Secondary prevention Instituted early after a condition has begun (but may not yet have been diagnosed) and before significant impairments have occurred., 417–418, 426
Selection, optimization and com- pensation (SOC) model, 415–416, 423
Selective serotonin uptake inhibitors (SSRIs), 285
Self-concept The organized, coherent, integrated pattern of self-perceptions., 264, 273
Self-efficacy, 345 Self-neglect, 318 Self-perception of aging Refers
to individuals’ perceptions of their own age and aging, 224–225, 244
Self-reports People’s answers to questions about a topic of interest., 18, 31
Semantic memory Learning and remembering the meaning of words and concepts that are not tied to specific occurrences of events in time., 164–165, 172, 184
Sensorimotor period, 200 Sensory memory A very brief
and almost identical representation of the stimuli that exists in the observable environment., 160, 184
Sensory systems, 69–76 Separation distress Expression of
complicated or prolonged grief disorder that includes preoccupation with the deceased to the point it interferes with everyday functioning, upsetting memories of the deceased, longing and searching for the deceased, and isolation fol- lowing the loss., 398, 404
Sequential designs Types of developmental research designs involving combi- nations of cross-sectional
and longitudinal designs., 23–26, 31
Serotonin, 39 Serotonin and norepinephrine
reuptake inhibitors (SNRIs), 285
Sex, Romance, and Relationships study, 80
Sex in America study, 80 Sexual abuse, 318 Sexual harassment, 355–356 Sinemet® (a combination of
levodopa and carbidopa), 300
Single parents, 331 Single photon emission
computerized tomography (SPECT), 34
Singlehood, 319 Situational attribution An
explanation for someone’s behavior that is external to the actor, 230, 244
Skin, 62 Sleep, 85–86 Smartphones, 175 illus Smell, 75–76 Social beliefs, 204–205
age differences in, 223–224 self-perception, 224–225
Social cognition, 216–242 attributional biases, 230–232 impression formation, 226–228 personal control, 235–238 self-perception, 224–225 social beliefs, 223–225 social judgment, 226–232 social knowledge, 228–229 social policy implications, 240 social processing goals, 232–235 social situations, 238–240 source judgments, 228–229 stereotypes, 217–222
Social cognitive career theory (SCCT) Proposes career choice is a result of the appli- cation of Bandura’s social cognitive theory, especially the concept of self-efficacy., 344–345, 374
Social facilitation of the nonuse of competence, 415–416
Social judgment, 226–232 age differences in, 229–230 attributional biases, 230–232 impression formation, 226–228 knowledge accessibility, 228–229 negativity bias, 228 source judgments, 229
Social knowledge A cognitive structure that represents one’s general knowledge about a given social concept or domain., 228, 244
Social policy implications Alzheimer’s disease, 305–306 cognitive enrichment
programs, 212
elder abuse prevention, 337–338 equal pay for equal work, 370 fall prevention, 87 graying of America, 180 long-term care financing, 153 memory and aging, 180 neuroscience and aging, 52 personality, 270 physical changes, 87 research, 27 social cognition, 240
Social security, 409–412 Social-emotional cognition, 44 Sociocultural age, 14 Sociocultural forces One of the four
basic forces of development that includes interpersonal, societal, cultural, and ethnic factors., 11, 31
Socioeconomic factors, 121 Socioemotional selectivity A theory
of relationships that argues that social contact is motivated by a variety of goals, includ- ing information seeking, self-concept, and emotional regulation., 313, 341
Sodium, 80 Somesthesia, 73 Source judgments Process of
accessing knowledge wherein one attempts to determine where one obtained a par- ticular piece of information., 229, 244
Source memory The ability to remember the source of a familiar event as well as the ability to determine if an event was imagined or actually experienced., 170–171, 184
Spaced retrieval A behavioral, implicit-internal memory intervention used in early- and middle-stage dementia., 297, 309
Spatial orientation, 24f, 25f, 191 Special care units, 145–146 Speed dating, 314 Speed of processing How quickly
and efficiently the early steps in information processing are completed., 160–161, 184
Spiritual support Includes seeking pastoral care, participating in organized and nonorga- nized religious activities, and expressing faith in a God who cares for people as a key factor in understanding how older adults cope., 268–269, 273
Stability-change issue A debate over the degree to which people remain the same over time as opposed to being different., 15, 31
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GLOSSARY/SUBJECT INDEX I-19
Stalevo® (a combination of Sinemet® and entacapone), 300
State processes A structural com- ponent of personality that acts with dispositional traits to create transient, short- term changes in emotion, mood, hunger, anxiety, etc., 247, 273
Statins, 421t Stepparents, 331–332 Stereotype threat An evoked
fear of being judged in accordance with a negative stereotype about a group to which an individual belongs., 221–222, 244
Stereotypes Beliefs about char- acteristics, attributes, and behaviors of members of cer- tain groups., 217–222, 244
activation, 220 content, 218–219 implicit, 220–221 perceived competence, 219
Storage The manner in which information is represented and kept in memory., 163, 184
Strategies Various techniques that make learning or remember- ing easier and that increase the efficiency of storage., 166, 184
Stress, 103–107 appraisal, 104–105 coping, 105, 132–133 health effects, 107 physiological state, 103–104
Stress and coping paradigm A model that views stress not as an environmental stimulus or as a response but as the interaction of a thinking person and an event., 104, 126
Stress incontinence A type of incontinence that happens when pressure in the abdomen exceeds the ability to resist urinary flow, 112, 126
Structural neuroimaging A set of techniques that provides highly detailed images of anatomical features in the brain., 34, 56
Structure of intelligence The organization of interrelated intellectual abilities., 191, 215
Subjective well-being An evaluation of one’s life that is associated with positive feelings., 265, 273
Substance abuse, 304–306 Substantia nigra, 299 Successful aging, 422–424
approaches to, 422–423 criteria, 422–423 critiques, 423–424 strategies, 416t subjective experience, 423 illus
Suicide, physician-assisted, 381–382
Sundowning The phenom- enon in which people with Alzheimer’s disease show an increase in symptoms later in the day., 291, 309
Synapse The gap between neurons across which neurotransmit- ters travel., 37, 56
Systematic observation A type of measurement involving watching people and carefully recording what they say or do., 18, 31
Tai Chi, 74 Tasks, 18 Taste, 75 Teachers, job satisfaction of,
347–349 Telomerase An enzyme need in
DNA replication to fully reproduce the telomeres when cells divide., 59, 91
Telomeres Tips of the chromo- somes that shorten with each replication., 59, 91
Temporary global amnesia (TGA) Temporary experience of a complete memory loss and disorientation in time., 178, 184
Terkel, Studs, 344 Terminal branches The end-
points in a neuron that help transmit signals across the synapse., 37, 56
Terror management theory Addresses the issue of why people engage in certain behaviors to achieve particular psychological states based on their deeply rooted concerns about mortality., 385, 404
Tertiary aging Rapid losses occurring shortly before death., 13, 31
Tertiary prevention Involves efforts to avoid the devel- opment of complications or secondary chronic conditions, manage the pain associated with the primary chronic condition, and sustain life through medical intervention., 418, 426
Thanatology The study of death, dying, grief, bereavement, and social attitudes toward these issues., 376, 404
Thatcher, Margaret, 275 thioridazine HCl (Mellaril®), 303 Time-of-measurement effects,
One of the three fundamen- tal effects examined in devel- opmental research, along with age and cohort effects, which result from the time at which the data are collected, 20–21, 31
Tip-of-the-tongue (TOT) experience, 165
Tissue plasmogen activator (TPA), 80
T-lymphocytes, 101–102 Torres, Dara, 2, 58 Trait Any distinguishable,
relatively enduring way in which one individual differs from others., 248, 273
Trait theories Theories of personality that assume little change occurs across adulthood., 248, 273
Transracial adoption, 332 Traumatic brain injury (TBI),
178–179 Traumatic distress Expression of
complicated or prolonged grief disorder that includes feeling disbelief about the death, mistrust, anger, and detachment from others as a result of the death, feeling shocked by the death, and the experience of physical presence of the deceased., 398, 404
Type I diabetes A type of diabetes that tends to develop earlier in life and requires the use of insulin; also called insulin- dependent diabetes, 108, 126
Type II diabetes A type of diabe- tes that tends to develop in adulthood and is effectively managed through diet, 108, 126
Underweight, 421t Unemployment, 358–359 Unexercised ability The ability of
normal, healthy adult would exhibit without practice or training., 208, 215
United States employment of women by indus-
try, 1964-2010, 352f grief processing and avoidance,
396–397 minority population
(1995–2050), 7f population trends, 5–7 projected population (2025), 6f projected population (2050), 6f projected population (2100), 7f resident population (2000), 5f
Universal versus context-specific development controversy
A debate over whether there is a single pathway of development, or several., 16–17, 31
Urge incontinence A type of incontinence usually caused by a central nervous system problem after a stroke or uri- nary tract infection in which people fee the urge to urinate but cannot get to a toilet quickly enough, 112, 126
Vacco v. Quill, 381 Validity The degree to which an
instrument measures what it is supposed to measure., 17–18, 31
Vascular dementia A form of dementia caused by a series of small strokes, 299, 309
Verbal meaning, 24f, 25f, 191 Vertigo, 74 Viagra, 84 Violence, in relationships, 316–318 Vision, 69–71 Vital functions, 76–81 Vitamin D, 65, 66t Voice, 63 Volunteering, 370 Vulnerability-stress-adaptation
model A model that sees marital quality as a dynamic process resulting from the couple’s ability to handle stressful events in the context of their particular vulnerabilities and resources., 322, 323f, 341
WanderGuard® device, 296 illus Washington v. Glucksberg, 381 Well-being, 264–265
emotion, 264–265 personality, 264–265 quality of life, 414–415, 426 subjective, 265, 273
Wernicke-Korsakoff’s syndrome, 300
Whitbourne’s identity theory, 262–263
White matter hyperintensities (WMH) Abnormalities in the brain often found in older adults; correlated with cognitive decline, 39–40, 56
White matter Neurons that are covered by myelin that serve to transmit information from one part of the cerebral cortex to another or from the cerebral cortex to other parts of the brain., 39, 56
Whole-brain death Death that is declared only when the deceased meets eight criteria established in 1981., 378, 404
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I-20 GLOSSARY/SUBJECT INDEX
Widowhood, 328 Winehouse, Amy, 376 Wisdom, 211–212 Women
caregivers, 360–361 dependent care dilemma,
360–361 earnings as percent of men’s,
355f employment by industry, 352f gender discrimination, 353–355 glass ceiling, 354 glass cliff, 354 household chores, 361–362 labor force participation in
selected countries, 351f occupational development,
352–353 occupational selection, 351–352
Women’s Health Initiative, 83 Word fluency, 24f, 25f, 191
Work, 353–356 age discrimination, 356 alienation, 349 burnout, 349 career construction theory, 344 dependent care dilemma,
360–361 discrimination, 353–356 equal pay for equal work, 355 and family, 360–363 gender bias, 353–354 job satisfaction, 347–349 late life, 369–370 meaning of, 344 mentors and coaches, 346–347 occupational choice, 344–345 occupational development,
345–347, 352–353 occupational expectations,
345–346 occupational insecurity, 357–358
occupational selection, 351–352 occupational transition,
356–359 older workers, 369–370 passion, 349–350 personality-type theory, 344 reality shock, 346 retraining workers, 357 sexual harassment, 355–356 social cognitive career theory,
344–345 social policy implications, 370 work-family conflict, 362–363
Work–family conflict The feeling of being pulled in multiple directions by incompat- ible demands from job and family., 362–363, 374
Working (Terkel), 344 Working memory Refers to the
processes and structures
involved in holding informa- tion in mind and simultane- ously using that information, sometimes in conjunction with incoming information to solve a problem, make a decision, or learn new information., 163–164, 184
Zone of maximum comfort In competence-environmental press theory, area in which slight decreases in environmental press occur., 130, 156
Zone of maximum performance potential In competence- environmental press theory, area in which increases in press tend to improve performance., 130, 156
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- Brief Contents���������������������
- Contents���������������
- Preface��������������
- About the Author�����������������������
- Ch 1: Studying Adult Development and Aging�������������������������������������������������
- 1.1: Perspectives on Adult Development and Aging�������������������������������������������������������
- 1.2: Issues in Studying Adult Development and Aging����������������������������������������������������������
- 1.3: Research Methods����������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 2: Neuroscience as a Basis for Adult Development and Aging��������������������������������������������������������������������
- 2.1: The Neuroscience Approach�������������������������������������
- 2.2: Neuroscience and Adult Development and Aging��������������������������������������������������������
- 2.3: Making Sense of Neuroscience Research: Explaining Changes in Brain-Behavior Relations�������������������������������������������������������������������������������������������������
- 2.4: Neural Plasticity and the Aging Brain�������������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 3: Physical Changes�����������������������������
- 3.1: Why Do We Age? Biological Theories of Aging�������������������������������������������������������
- 3.2: Appearance and Mobility�����������������������������������
- 3.3: Sensory Systems���������������������������
- 3.4: Vital Functions���������������������������
- 3.5: The Reproductive System�����������������������������������
- 3.6: The Autonomic Nervous System����������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 4: Longevity, Health, and Functioning�����������������������������������������������
- 4.1: How Long Will We Live?����������������������������������
- 4.2: Health and Illness������������������������������
- 4.3: Common Chronic Conditions and Their Management����������������������������������������������������������
- 4.4: Pharmacology and Medication Adherence�������������������������������������������������
- 4.5: Functional Health and Disability��������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 5: Where People Live: Person-Environment Interactions
- 5.1: Describing Person-Environment Interactions
- 5.2: The Ecology of Aging: Community Options���������������������������������������������������
- 5.3: Living in Nursing Homes�����������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 6: Attention and Memory���������������������������������
- 6.1: Information Processing and Attention������������������������������������������������
- 6.2: Memory Processes����������������������������
- 6.3: Memory in Context�����������������������������
- 6.4: Self-Evaluations of Memory Abilities������������������������������������������������
- 6.5: Memory Training���������������������������
- 6.6: Clinical Issues and Memory Testing����������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 7: Intelligence, Reasoning, Creativity, and Wisdom������������������������������������������������������������
- 7.1: Defining Intelligence���������������������������������
- 7.2: Developmental Trends in Psychometric Intelligence�������������������������������������������������������������
- 7.3: Qualitative Differences in Adults' Thinking
- 7.4: Everyday Reasoning and Problem Solving��������������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 8: Social Cognition�����������������������������
- 8.1: Stereotypes and Aging���������������������������������
- 8.2: Social Knowledge Structures and Beliefs���������������������������������������������������
- 8.3: Social Judgment Processes�������������������������������������
- 8.4: Motivation and Social Processing Goals��������������������������������������������������
- 8.5: Personal Control����������������������������
- 8.6: Social Situations and Social Competence���������������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 9: Personality������������������������
- 9.1: Dispositional Traits across Adulthood�������������������������������������������������
- 9.2: Personal Concerns and Qualitative Stages in Adulthood�����������������������������������������������������������������
- 9.3: Life Narratives, Identity, and the Self���������������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 10: Clinical Assessment, Mental Health, and Mental Disorders����������������������������������������������������������������������
- 10.1: Mental Health and the Adult Life Course����������������������������������������������������
- 10.2: Developmental Issues in Assessment and Therapy�����������������������������������������������������������
- 10.3: The Big Three: Depression, Delirium, and Dementia��������������������������������������������������������������
- 10.4: Other Mental Disorders and Concerns������������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 11: Relationships���������������������������
- 11.1: Relationship Types and Issues������������������������������������������
- 11.2: Lifestyles and Love Relationships����������������������������������������������
- 11.3: Family Dynamics and the Life Course������������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 12: Work, Leisure, and Retirement�������������������������������������������
- 12.1: Occupational Selection and Development���������������������������������������������������
- 12.2: Gender, Ethnicity, and Discrimination Issues���������������������������������������������������������
- 12.3: Occupational Transitions�������������������������������������
- 12.4: Work and Family����������������������������
- 12.5: Leisure Activities�������������������������������
- 12.6: Retirement and Work in Late Life���������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 13: Dying and Bereavement�����������������������������������
- 13.1: Definitions and Ethical Issues�������������������������������������������
- 13.2: Thinking about Death: Personal Aspects���������������������������������������������������
- 13.3: End-of-Life Issues�������������������������������
- 13.4: Surviving the Loss: The Grieving Process�����������������������������������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- Ch 14: Successful Aging������������������������������
- 14.1: Demographic Trends and Social Policy�������������������������������������������������
- 14.2: Health Issues and Quality of Life����������������������������������������������
- 14.3: Successful Aging�����������������������������
- Summary��������������
- Review Questions�����������������������
- Integrating Concepts in Development������������������������������������������
- Key Terms����������������
- References�����������������
- Name Index�����������������
- Glossary/Subject Index�����������������������������
