Discussion Posts

Student 2018

Chapter3-7.pdf

Home >Applied Sciences homework help >Discussion Posts

PART II

THE REALITIES OF GROWING OLDER

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

Al l ri gh ts r es er ve d. M ay n ot b e re pr od uc ed i n an y fo rm w it ho ut p er mi ss io n fr om t he p ub li sh er , ex ce pt f ai r us es p er mi tt ed u nd er U .S . or a pp li ca bl e co py ri gh t la w.

EBSCO : eBook Collection (EBSCOhost) - printed on 5/7/2018 6:06 PM via UTICA COLLEGE AN: 672926 ; Sugar, Judith.; Introduction to Aging : A Positive, Interdisciplinary Approach Account: s8331415.main.ehost

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

1CHAPTER

Physical Changes and the Aging Process

The learning objectives of this chapter include understanding

The three basic theories of aging: rate-of-living, aging as an adaptive program, and evo- ■ lutionary senescence. The distinction between normal physical changes that accompany aging and the dis- ■ eases and conditions that are more common with age. The normal physical changes that accompany aging. ■ The adaptations that older people can make to accommodate normal physical changes. ■ That attention to normal physical changes can prevent serious consequences for older ■ people.

EVERYBODY IS A LITTLE DIFFERENT—EVEN THE OLD

Sam is 73 and works out several times a week. He lifts weights at least three times a week and jogs almost every day. He also runs in several marathons a year. He skis, swims, plays softball in a league for people age 70 and older, and is proud of the fact that he can do more pushups than his 19-year-old grandson. He walks with vigor and has a strong, fi rm voice and an even stronger handshake. He says he might reduce his vigorous schedule on his 90th birthday, or by then he might decide to take up skydiving!

Josephine is 77. She thinks that exercising is for young people and that older people who engage in physical activity are risking a heart attack. She says that by the time you get into your late 70s, you just don’t do much, and she doesn’t. Most days, Josephine just stays in her home and putters around.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

38 II. THE REALITIES OF GROWING OLDER

BIOLOGICAL THEORIES OF AGING

Biologists will tell you that aging is a part of the circle of life. We all begin aging from the day we are born, with the process of aging proceeding at different rates for different body parts, functions, and abilities. From a biological point of view, aging has been defi ned as the gradual decline in physiological functions as a consequence of increasing chronologi- cal age. Beginning in the late 1800s, ideas about the causes of aging have proliferated to the point where as many as 300 such ideas have been put forward to date. Most of these ideas can be organized into three basic theories of aging: rate-of-living, aging as an adap- tive program, and evolutionary senescence. To date, only the evolutionary senescence theory has suffi cient evidence to support it, although it requires further development (Austad, 2009).

Rate-of-Living Theory

The basic idea of the rate-of-living theory is that biological aging is a consequence of accumulating tissue and organ damage, an inherent result of the body’s use of energy to support cellular and molecular processes (Austad, 2009). The ideas that oxygen-free radicals or oxidative stress cause aging are among those related to this mechanistic the- ory. Much evidence refutes this theory, however. For example, the theory predicts that a faster metabolism should result in faster aging. But this is not the case for all species. In fact, based on the amount of energy expended daily per unit of body mass, some smaller animals who expend much more energy, nevertheless live signifi cantly longer than larger animals who expend much less energy (Speakman, van Acker, & Harper, 2003).

Aging as an Adaptive Program

The basic idea that aging could be adaptive for the human species is that it is best to mini- mize competition for resources in a species by eliminating “old and decrepit” individuals for the benefi t of the young (Weismann, 1882). The problem with this evolutionary point of view, however, is that if individuals did not age, they would not become decrepit. In addition to the circular thinking in the adaptive program argument, there are other problems with this theory. For this theory to be correct, group selection would have to be a prevalent phenomenon in all species, which is defi nitely not the case (Rose, 1991). The theory in its current state of development also cannot explain differences in aging rates between species, or why it is that large species generally live longer than do small spe- cies (Austad, 2009). So this theory, and ideas related to it, do not seem to be promising avenues for explaining the causes of aging.

Evolutionary Senescence Theory

Evolutionarily speaking, genes are selected for or selected against only if they affect the number and survival of offspring. The basic idea of the evolutionary senescence theory, a term coined by Austad (2009), is that actions of our genes over our lifetime cause aging. Two mechanisms for such gene actions have been proposed: mutation accumulation (Medawar, 1952) and antagonistic pleiotropy (Williams, 1957).

The mutation accumulation hypothesis proposes that genes with negative effects on survival in late life accumulate in the genome, causing the decline and damage that we associate with aging. Genes, whose negative effects on survival appear only later in life, will continue to exist in the genome and thus be passed from generation to generation

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

3. PHYSICAL CHANGES AND THE AGING PROCESS 39

because they do not affect offspring production. A good example of this principle can be found in Huntington’s disease, an almost entirely inherited disease. Most people who are carriers of Huntington’s have already had their children, and hence passed on the disease to the next generation, by the time they are diagnosed. Though Huntington’s is a rare disease, its prevalence could be signifi cantly reduced, if genetic testing became widely used.

The basic idea of the antagonistic pleiotropy hypothesis is that some genes that confer positive benefi ts early in life, and are therefore selected for, can also confer nega- tive effects later in life. Pleiotropy means that one gene infl uences more than one observ- able characteristic of an organism. In antagonistic pleiotropy, one of these effects is benefi cial and another is detrimental. One example comes from considering the possi- bility that one allele could have a positive effect on bone growth during an individual’s early stages of development, but a negative effect of depositing excess calcium within arterial walls later in life (Williams, 1957), which could lead to high blood pressure and blood clots, increasing the risk of strokes and heart attacks. The preponderance of evidence currently supports antagonistic pleiotropy as the best explanation for evolu- tionary senescence.

Rate of Aging: Caloric Restriction, Human Growth Hormone, and Exercise

Whatever the cause of aging, there is much interest in discovering ways to decrease the rate at which aging takes place. There are very large differences among individuals in the aging process. Among the possible ways of changing the rate of aging, caloric restriction, the use of human growth hormone (hGH), and physical activity have all been suggested. Caloric restriction refers to the idea that perhaps aging can be slowed by decreasing the number of calories consumed each day. In fact, caloric restriction has been demonstrated to delay the aging process, prevent the onset of aging-related diseases, and increase the life span of several invertebrate organisms, as well as laboratory rats, although the rea- sons for these outcomes are not yet known (Xiang & He, 2011). Nevertheless, the extent to which reducing daily food consumption might increase humans’ life span has yet to be determined. Furthermore, it is not at all clear that many people would look favorably on reducing their caloric intake to a level that might be necessary to slow the aging pro- cess. In the case of human growth hormone, its many dangerous side effects also do not bode well for it having a role in slowing individuals’ aging processes. Physical activity, however, has much promise in keeping people healthy throughout their life span. The importance of physical activity for older adults is discussed in the chapter on Health, Wellness, and Normal Aging.

NORMAL PHYSICAL CHANGES THAT ACCOMPANY AGING AND ADAPTATIONS TO THEM

Most researchers who focus on the aging processes have pointed out that normal aging can be differentiated from the diseases and conditions that are more common as we age, for example, arthritis and heart disease. Furthermore, there is no specifi ed common time- table for human aging; instead, there are enormous individual differences in the aging process, and all older people do not experience all the documented possible changes.

Nevertheless, as people grow older, changes tend to occur throughout the physical systems of the body that may be hardly noticeable at fi rst. Among the physical changes that can be expected to occur as we age, some, such as gray hair and wrinkling skin, are more visible, while others, such as hearing loss and hypothermia, may be less visible.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

40 II. THE REALITIES OF GROWING OLDER

Hair

One of the most noticeable physical changes that occur with aging is hair color turning gray or white. No one knows why specifi c hairs turn gray or white and others do not. Within each hair follicle (tubelike organs in the skin) are cells that add color to the hair shaft. Each specifi c hair grows for about three years, then rests for several months before it starts growing again. As one ages, the color-producing cells cease functioning, and the hair grows out gray or white. At the present time, there is no known process to help those cells continue producing their original color. It is known that there is a genetic component to the action of those cells, and as a result, persons whose ancestors’ hair turned gray early in life have a higher probability of developing gray hair (Saxon, Etten, & Perkins, 2010). Many older adults adapt to this change by coloring or dyeing their hair.

Skin

As people grow older, their skin begins to wrinkle. For most people that process begins in their 20s. The process is accelerated by smoking and frequent exposure to the sun. The wrinkling process also relates to a person’s genetic heritage. The skin of blonde, pale-skinned people tends to wrinkle sooner than it does for those with darker skin. In addition, as a person ages their skin becomes drier and more susceptible to cracking. That process is accelerated by dry air and exposure to the sun (Saxon et al., 2010).

Adaptations for age-related changes to our skin abound. One is to minimize the effects of the sun by avoiding prolonged direct exposure and using a sunscreen lotion that offers good protection from ultraviolet A and B solar radiation. Tanning parlors are also something to be avoided. Rooms should be kept moist so that dry skin will not crack. If a humidifi er is unaffordable, pans of water placed on a heat register can be used to put moisture into the air. In addition, liberal use of creams and ointments softens dry skin thereby prevent cracking. Massages and facials are excellent choices for hydrating the skin. Manicures and pedicures can also be helpful because they involve massaging creams into the hands and feet.

Temperature Control

Elderly people do not adjust to temperature changes as well as young people , and they are more likely to take prescription medications or have a chronic medical condition that changes their body’s ability to regulate its temperature. For these reasons, older people are more prone to negative effects of cold temperatures, which can result in hypothermia, and also to hot temperatures, which can result in heat stress. Both hypothermia and severe heat stress can be fatal, so they require immediate medical attention.

Hypothermia

With age comes a loss of subcutaneous fat, and a diminished fl ow of blood to the skin and extremities, so there is an increased danger of hypothermia for older persons. Hypothermia is a reduction in body temperature, with a danger that the body temper- ature will get so low that a person’s life may become endangered. Research seems to indicate that the danger of hypothermia among older persons is much greater than previ- ously believed. Hypothermia can even result in death, although it is often overlooked as a cause of death. Thus, it is important to know the symptoms of hypothermia. One should be alert for the umbles—stumbles, mumbles, fumbles, and grumbles. Check for confusion

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

3. PHYSICAL CHANGES AND THE AGING PROCESS 41

or sleepiness; slow, slurred speech or shallow breathing; weak pulse; irregular heartbeat; a lot of shivering or no shivering; stiffness in the arms or legs; poor control over body movements; or slow reactions. Whenever an older person has any of these symptoms and their temperature drops to 96°F or below, immediate medical attention should be sought (National Institute on Aging, 2010).

Prevention of hypothermia among older adults, especially those aged 75 or older, is quite simple: Room temperatures should be maintained at no less than 68°F, and warm outdoor clothing appropriate for the temperature should be worn when temperatures fall. It should be noted that a room temperature that is comfortable for older people may seem too hot for those who are younger. There is a special problem in nursing facili- ties where a comfortable room temperature for the residents is usually too warm for the younger, active staff (Aging in Michigan, 1992). Older adults also need to be sure to wear adequate clothing in cold temperatures.

Heat Stress

Heat stroke is the most serious heat-related illness. It occurs when the body becomes unable to control its temperature. Warning signs vary but may include an extremely high body temperature (above 103°F); red, hot, and dry skin, with no sweating; a rapid, strong pulse; a throbbing headache; dizziness; and nausea. Heat exhaustion is a milder form of heat-related illness that can develop after several days of exposure to high temperatures and inadequate or unbalanced replacement of fl uids. Warning signs may include heavy sweating, paleness, muscle cramps, tiredness, weakness, dizziness, headache, nausea or vomiting, fainting, cool and moist skin, a fast and weak pulse, and fast and shallow breathing. Prevention of heat stress includes drinking cool, non- alcoholic beverages; resting; taking a cool shower or bath; wearing lightweight cloth- ing; not engaging in strenuous activities; and, if possible, seeking an air-conditioned environment or remaining indoors in the heat of the day. For any signs of severe heat stress, medical attention should be sought immediately (Centers for Disease Control and Prevention, 2009).

Vision

Only 18% of older adults report any trouble seeing (Older Americans 2010). Even so, sev- eral changes occur in our eyes as we age, including presbyopia (farsightedness), dry eyes, and cataracts, all of which can be dealt with relatively simply nowadays. These changes usually occur after the age of 40, but younger people can also experience them. There are numerous ways to adapt to aging eyes so that a good quality of life can be maintained throughout the life span. (More serious eye conditions, including glaucoma and macular degeneration, are discussed in Chapter 14.)

Presbyopia/Farsightedness

Presbyopia, or farsightedness, usually begins to develop when a person is about 40 years of age. Presbyopia is a normal condition, not a disease, and should not disrupt the daily lives of most people. As we age, our eyes begin to lose the ability to adjust for different distances, and eventually most people will need bifocals or trifocals to maintain good vision. Presbyopia also means that as a person grows older, it is more diffi cult to adjust to darkness and to glare, and it takes more time to adapt to changes in light and darkness. These changes in vision make nighttime driving more hazardous for older people.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

42 II. THE REALITIES OF GROWING OLDER

Cataracts

Cataracts are very common in older adults, though they can occur in children too. Research has shown that the risk of cataracts is related to frequent sun exposure, which has its greatest effects on younger people (Neale, Purdie, Hirst, & Green, 2003). Protecting our eyes from intense sunlight throughout our life span will decrease susceptibility to cataracts. Eventually, though, most people will develop cataracts if they live long enough. Cataracts result in increasingly blurred or misty vision as the eye’s lens becomes milky. Some cataracts grow larger or denser over time, causing severe vision changes. These cataracts can cause loss of independence for older adults because decreased vision may affect driving, working, reading, or hobbies. In the United States, cataract surgery, which replaces the clouded lens with a synthetic one, is the most commonly performed surgery in adults over age 65. Its success rate is very high. Cataract growth can be slowed by pro- tecting our eyes from the sun and from sunlamps, eating healthy foods, limiting alcoholic drinks, and avoiding smoking (Kline & Wenchen, 2005).

Dry Eyes

Some people develop dry eyes as they grow older. This dryness can also cause redness in the eye. Mild cases can usually be treated with over-the-counter artifi cial tear solutions. Optometrists can diagnosis and recommend other treatments for more serious cases of dry eye (American Optometric Association, n.d.).

Some age-related changes in vision can be dealt with by wearing bifocals or trifocals for presbyopia, by surgery for cataracts, and by using artifi cial tears for dry eyes. Most other changes are best dealt with by changes to our environment. Our built environ- ment has been constructed using parameters that work best for young people. Thus, the amount of light, the existence of stairs and escalators, and the typical size of print, for example, have all been determined for the society we used to be—a society of mostly young people. With our changing demographics, and our desire to make our environ- ment more accessible to people with disabilities, it is time for us to make changes to our existing environment, and rethink parameters for future built environments, to accom- modate people of all ages and ability levels.

As we age, we require more light to see as well as we did when we were younger (as much as a threefold increase). Thus, simply increasing the amount of light assists older eyes to see better. Depth perception is also affected, so constructing environments that clearly differentiate changes in levels, for example on stairways, is a good way to increase visibility of those changes, and thus help decrease falls in older people. Varying textures, materials, and colors is often helpful in signaling level changes, too. And, ramps are preferable, especially to escalators, for moving from one level to another because they are much safer for everyone.

A few serious conditions can develop more readily in older people, and thus require periodic eye examinations by qualifi ed professionals (e.g., opthalmologists). These serious vision conditions—macular degeneration, glaucoma, and retinopathy— are discussed in the Medical Care chapter. In general, a complete eye examination is recommended for those older than age 45, and then follow-up examinations every 2 to 4 years thereafter.

Hearing

As we age, limitations in our hearing become much more common than limitations in our vision. In 2008, 28% of people age 65 to 74 years reported trouble hearing, and that percentage rose to 60 for people age 85 and over. Older men are almost 50% more likely to have hearing problems than are older women (Older Americans 2010). As people grow Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

3. PHYSICAL CHANGES AND THE AGING PROCESS 43

older, a condition known as presbycusis occurs. This refers to a loss in hearing brought about by various, not well-understood, age-related changes. Most people lose the ability to hear high-pitched sounds fi rst, which leads to poor hearing when there is background noise, and major diffi culty hearing women’s and children’s voices, and distinguishing different words because consonants, such as Bs and Ps, and Cs and Ks, tend to be higher pitched than are vowels. Presbycusis can occur because of changes in the inner ear, audi- tory nerve, middle ear, or outer ear. Some of its causes are aging, loud noise, heredity, head injury, infection, illness, certain prescription drugs, and circulation problems such as high blood pressure.

An important factor in hearing loss is the increasing isolation of the person with impaired hearing. For most people, hearing loss is gradual. At the beginning of the loss of hearing, it is not unusual for people to be irritable, to seem to be distracted from conver- sation, and to be unsociable. Often a person may be unaware of the hearing loss and fre- quently give inappropriate answers to questions that he or she did not hear adequately. As a result, relationships may become strained as others believe him or her to be a bit confused. As this process continues, the person may begin to feel rejection conveyed in the nonverbal communication of others, and there is a real danger that depression may set in (Gopinath et al., 2009), leading to a cyclical process in which he or she becomes even more isolated and more depressed.

Hearing is an essential component of well-being, especially for people who have enjoyed normal hearing for most of their lives. Losing the ability to hear adequately in the routine activities of daily life can be very detrimental. Older adults with moderate to severe hearing loss report more diffi culty with tasks such as preparing meals, shopping, and using the telephone than do those with no hearing loss (Gopinath et al., 2012). Once daily activities such as these become compromised, independence and quality of life can be reduced.

Adaptations to age-related changes in hearing involve those communicating with older people as well as the older people themselves. In communicating with people who have hearing problems, it is helpful to speak slowly and enunciate clearly. Shouting should be avoided. It is benefi cial to speak face-to-face so the person can see lip move- ments. Because much communication is nonverbal, one can attempt to communicate emotions, moods, and acceptance by body language and facial expressions. It is always helpful to eliminate background noise, including noise created by fans, air conditioners, and other appliances. It is important that the acoustics in an auditorium be very good for a presentation to older persons. In addition, it is wise to use good sound equipment, because most people experience some hearing loss as they grow older.

Older persons who believe they are suffering hearing loss can benefi t from having a hearing checkup with an audiologist or with an ear, nose, and throat specialist. If there is signifi cant organic reason for hearing loss, many aids are available today that can help. It is important for a person to be diagnosed by a certifi ed specialist, such an audiologist, and not by a person who only sells hearing aids. Unfortunately, most people who could bene- fi t from some type of hearing aid do not have one. In the fi rst national study that included audiometric testing of a large, representative sample, Chien and Lin (2012) analyzed data from the National Health and Nutritional Examination Surveys (NHANES) on hearing loss and hearing aid use. Of the 27 million Americans 50 years of age or older with a hearing loss, they found that only 3.8 million (14%) used hearing aids. A variety of reasons have been suggested for the relatively low-level use of hearing aids. Some people feel that they cannot afford them—hearing aids are expensive and are not covered by Medicare. Others are concerned about the stigma associated with wearing a hearing aid. There are also those who think their hearing loss is relatively minor, and they would rather not bother with hearing aids, which do not restore the entire range of lost frequencies and still do Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

44 II. THE REALITIES OF GROWING OLDER

not eliminate distracting background sounds in a noisy environment. At fi rst, a hearing aid may seem unnatural and strange because it amplifi es sounds other than speech. It usually takes some time to adjust to a hearing aid, and families and friends, as well as the user of the aid, will need patience during the adjustment process. Modern hearing aids are marvels of technological advancement. Many types are available, including ones that fi t in the ear canal (completely or partly), in the ear, or behind the ear. Most have been miniaturized so that they are comfortable to wear and are cosmetically acceptable. Hearing aids can be indistinguishable in their appearance from earpieces for electronic devices, so the stigma of wearing a hearing aid may disappear in the near future!

Smell and Taste

Research suggests that our sense of smell becomes impaired with age, and to a lesser extent, taste sensitivity is also affected (Murphy, 2008). About 25% of persons aged 65 to 80 lose some ability to smell. After the age of 80, this increases to 50%. Usually people do not begin to lose their sense of smell until they are in their 50s. Apparently, what happens is that the sense receptors for odor in the upper nose begin to lose their ability to function because of disease or injury. In addition, odor-related brain acti- vation is signifi cantly reduced in normally aging persons (Cerf-Ducastel & Murphy, 2003).

When it comes to taste, in comparison to smell, much less is known about changes that may take place as we age or their causes, in part because distinguishing the effects of aging from the effects of a disease or medications can be very diffi cult. Some studies have found a decline in the number of taste buds while others have not, but in general, taste seems to remain a relatively intact sense as we age (Seiberling & Conley, 2004). Our sense of taste is important for the pleasures we derive from consuming good food as well as for helping us to avoid consuming harmful substances. It is important to note, too, that our smell and taste senses interact. For example, a person might prefer saltier food because increased saltiness can make up for a reduced ability to smell fl avor components.

Potentially serious problems can arise as a result of changes in our sense of smell and taste. A reduction in these sensory abilities can result in changes in food intake and selection, and, consequently nutritional status. Changes in salt perception can negatively impact the likelihood that hypertensive patients will maintain a low-salt diet, and changes in sweet perception can negatively impact the likelihood that diabetics will limit their sugar intake. Some older persons have diffi culty smelling gas leaks, smoke, and spoiled food. At the same time, they lose the pleasure of smelling fl owers, perfumes, and well- cooked and seasoned foods, which can lead to a diminished quality of life (Seiberling & Conley, 2004).

Adaptations for older adults with a decreased sense of smell include ensuring that smoke detectors are in place and working, and paying attention to food safety guidelines as well as expiration dates on food products. Friends, neighbors, and family members can be helpful in detecting problematic smells or tastes, too. When taste seems to be affected, the enjoyment of food can be enhanced by adding spices and incorporating a diversity of food fl avors, textures, and temperatures during meal preparation. “Eye appeal” can also positively affect enjoyment, so garnishes, variety in food colors, and placement of food on a plate should not be overlooked.

For additional information on tips for adapting to common aging-related changes in vision, hearing, touch, taste, and smell, consult the Practical Application at the end of Part II of this textbook.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

3. PHYSICAL CHANGES AND THE AGING PROCESS 45

Feet

By the time we reach old age, our feet have had years of wear and tear, so good foot care becomes especially important. Checking regularly for cuts, blisters, and ingrown toenails is a good practice; people with diabetes should check their feet every day. Raising feet when sitting helps keep blood moving to the feet. Stretching, walking, and gentle foot massages can serve a similar function. Warm footbaths are helpful, too. Wearing comfort- able shoes that fi t well can prevent many foot problems. Sometimes, foot problems are the fi rst sign of more serious medical conditions such as arthritis, diabetes, and nerve or circulatory disorders. In addition, foot pain contributes to falls in older adults (Mickle, Munro, Lord, Menz, & Steele, 2010). If there seems to be a foot problem, a podiatrist (foot specialist) can be consulted.

The Urinary Tract

Although some age-related changes occur in our kidneys, in the absence of disease, they usually continue to function quite well throughout the later years of life. “Exercise; proper diet, including adequate fl uid intake; limited use of medications; and quitting smoking help the urinary system maintain adequate functioning” (Saxon et al., 2010, p. 218). Bladder capacity does decline by 30% to 40%, but this is not a symptom of disease, it is simply a result of the aging process (Saxon et al., 2010). Most elderly persons need to get up in the night to empty their bladder. Older persons should know that having to arise in the night to go to the bathroom is not in itself an indication of any serious disease. If they have to arise more frequently than twice a night, however, they ought to see a health care professional.

The micturition refl ex changes as one ages. Micturition is the signal a person receives when he or she has to urinate. For a young person, that signal is usually sent when the bladder is about half full. As a result, young people have some time left before they must absolutely get to a bathroom. Not so for the elderly. The signal to urinate is given when the bladder is nearly full. Obviously that means when they receive the signal, there is not much time for delay. The reduced capacity of the bladder, coupled with a delayed signal to urinate, can lead to problems of frequent urination and the need to urinate immedi- ately (Saxon et al., 2010).

Some older persons also have a problem with dribbling urine or urinary inconti- nence (UI). This can be viewed as both physiologically and psychologically damaging. There is a higher probability that women will have incontinence than will men, likely the result of childbirth and the associated weakening of the bladder outlet and pelvic mus- culofascial attachments. Although UI is more common in older adults, people of any age can experience it. The most common type is stress incontinence, which is brought about by a laugh, a cough, a sneeze, or lifting. In addition to stress incontinence, some older per- sons suffer from urge incontinence, the sudden urge to go to the bathroom without time to get there. Others suffer from overfl ow incontinence, a condition in which the bladder becomes too full and urine leaks out (Saxon et al., 2010).

There is an increased chance of urinary tract infections as a person grows older. Symptoms of a bladder infection include cloudy or bloody urine, a low-grade fever, pain, or a burning sensation during urination, and a strong need to urinate often, even right after the bladder has been emptied. If the infection spreads to the kidneys, symptoms may include chills and shaking or night sweats; fatigue, fever above 100°F; mental changes or confusion; nausea and vomiting; and side, back, or groin pain. In either case, a health care professional should be consulted for diagnosis and treatment. A course of antibiotics usu- ally clears up infections fairly quickly.Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

46 II. THE REALITIES OF GROWING OLDER

Older people, especially older men, are at higher risk of developing kidney stones than are younger people. Kidney stones are hard masses that form in the kidney out of substances in the urine. They may be as small as a grain of sand or as large as a pearl. Some stones are even as big as golf balls! Most kidney stones pass out of the body with urine. But sometimes a stone will not pass by itself and then medical attention is neces- sary. The larger the stone, the more likely it is to cause severe pain, in the back or side, that will not go away. Other symptoms include fever and chills, vomiting, urine that smells bad or looks cloudy, a burning sensation during urination, or blood in the urine. The most common treatment is extracorporeal shockwave lithotripsy (ESWL), in which a machine sends shock waves to the stone and breaks it into smaller pieces, which can then be passed out of the body in urine. The best way to prevent kidney stones is to drink lots of water, which helps to fl ush away the substances that form kidney stones (National Kidney & Urologic Diseases Information Clearinghouse, 2011). Producing at least a liter (slightly more than a quart) of urine per day is indicative of drinking adequate fl uids.

Awareness of age-related changes in the urinary tract, including its reduced capac- ity, can also be helpful because then older people can plan to regularly visit lavatory facilities, and avoid foods and drinks that may cause them to urinate more often, thereby avoiding the incontinence that might ensue. Another adaptation older people can make to changes in their urinary tracts is to learn to do kegel exercises to strengthen pelvic muscles, which can even prevent urinary incontinence.

The Musculoskeletal System: Bones and Muscles

Bones play many roles in the body. They provide structure, protect organs, anchor mus- cles, and store calcium. Beginning early in life, engaging in regular weight-bearing physi- cal activity and eating foods that are rich in calcium and vitamin D (which helps the body to absorb calcium) build strong bones, optimize bone mass, and may reduce the risk of osteoporosis later in life. Bone thinning, or loss of bone mineral density, begins at about age 35 when the body begins to reabsorb bone cells faster than it makes new bone. Bone thinning, though, does not have to result in osteoporosis, a disease that weakens bones, making them more likely to break. It is important for young people, and espe- cially young women who are more susceptible to osteoporosis than are young men, to reach their peak bone mass (genetic potential for bone density) in order to maintain bone health throughout life. A person with high bone mass as a young adult will be more likely to have a higher bone mass later in life. Inadequate calcium consumption and physical activity early on could result in a failure to achieve peak bone mass in adulthood, result- ing in an increased risk for osteoporosis. Chapter 4 has more information on preventing osteoporosis.

Skeletal muscles help our body to move, keep our body upright and standing tall, and give us the power to lift things. Some even say that “the speed at which we age is down to how fast we allow our skeletal muscle to erode based on the physical and dietary decisions we make each day” (http://sarcopenia.com). Unfortunately, muscle mass begins to decrease in middle adulthood. Arts, Pillen, Overeem, Schelhaas, and Zwarts (2007) measured quadricep and bicep muscles in a sample of healthy men and women between the ages of 2 months and 90 years. Between 40 and 90 years of age, quadricep muscle thickness decreased by 50% in men and 30% in women; bicep muscles fared not much better, their thickness decreased by 30% in men and 20% in women.

Such declines in muscle mass, and the resulting declines in strength are associated with sarcopenia (from the Greek word for loss of fl esh). Although a full understanding

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://sarcopenia.com

3. PHYSICAL CHANGES AND THE AGING PROCESS 47

of the causes of sarcopenia does not yet exist, it is known that the likelihood of acquir- ing the condition increases with age and is related to the cumulative loss of muscu- loskeletal mass and strength due to insuffi cient exercise. Preventing saropenia, not surprisingly, requires muscle training of some kind. Resistance training, using free weights, resistance machines, or isometrics, has been the exercise method of choice for improving muscle strength. Although older adults seem to require more training than do younger adults, with the right exercise program, they are nevertheless able to increase muscle and maintain it as well as, or better than, their younger counter- parts who do not train (Bickel, Cross, & Bamman, 2011). Research is also showing that power training may be even more effective in improving functional independence because it enhances older adults’ ability to carry out activities of daily living (ADLs; Hazell, Kenno, & Jakobi, 2007). Of course, older people should consult their health care provider prior to beginning a new exercise program. Finally, mounting evidence suggests that a moderate increase in dietary protein to 1.0 to 1.2g/kg of weight per day for older adults (0.8 g/kg per day is currently recommended for adults aged 19 and older), distributed across the day’s meals, has benefi cial effects on both bone and muscle health (Gaffney-Stomberg, Insogna, Rodriguez, & Kerstetter, 2009; “New fi nd- ings on frailty and diet,” n.d.).

Menopause

Menopause, the cessation of menstruation, is a normal part of every woman’s life. Symptoms can begin several years earlier than the last period occurs. They include changes in menstruation (e.g., increasing variation in length of the cycle, lighter or heavier bleeding), hot fl ashes (sudden feelings of heat, usually in the upper part of the body, last- ing between 30 seconds and 20 minutes), vaginal drying, trouble sleeping, and mood changes. Some symptoms of menopause can last for months or years after. Changing levels of estrogen and progesterone are related to these symptoms. The average age for menopause is 51, but for some women it happens in their 40s, and some have it in their late 50s.

The majority of women experience some symptoms, though not all women fi nd them bothersome. Hot fl ashes and night sweats can be alleviated by sleeping in a cool room, drinking cold water or juice when a hot fl ash is coming on, dressing in layers, and using sheets and clothing that let the skin “breathe.” Exercise and slow, deep breathing may also help reduce hot fl ashes. Low-dose birth control pills will make menstrual cycles and fl ow more regular and also help with hot fl ashes. A water-based lubricant (but not petroleum jelly) may relieve vaginal discomfort, enabling a normal sex life. Sleep prob- lems may be relieved by adopting good sleep hygiene practices, such as adhering to a bedtime routine and creating a comfortable sleeping environment (see more suggestions in Chapter 4).

Some women require medication. Menopausal hormone therapy (MHT; or estro- gen replacement therapy [ERT] or hormone replacement therapy [HRT]) was a widely recommended treatment for menopausal symptoms until it was learned that side effects may include an increased risk of breast cancer and heart disease. The current recom- mendation for those women who can benefi t most from MHT is for them, in consulta- tion with their physician, to take the lowest dose of a combined estrogen–progesterone formula for the shortest time that is consistent with the reason for the therapy (National Institute on Aging, 2009). Like all prescription medications, MHT should be re-evalu- ated regularly.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

48 II. THE REALITIES OF GROWING OLDER

Sleep

Older adults need about the same amount of sleep as do young adults—7 to 9 hours each night. On the other hand, sleep patterns change with age. Seniors often need more time to fall asleep as they grow older. The amount of time spent in REM (rapid eye movement) sleep and non-REM sleep (the deepest and most restful sleep) shifts as we get older, with a decrease of time in deep sleep. Compared to younger people, seniors tend to sleep more lightly and awaken more quickly in response to noises. Once awake, they often fi nd it harder to get back to sleep.

It is not clear how many of the changes in sleep result from the normal aging pro- cess or from factors such as medications, lack of exercise, napping during the daytime, or disease. Seniors tend to take more medications than do younger people, and medica- tions and their side effects can impair sleep or even stimulate wakefulness. A sedentary lifestyle can lead to sleepiness all the time, or a lack of sleepiness. Sleep may be disturbed more frequently in old age by an increased probability of needing to urinate during the night, by rhythmic leg movements, or by sleep-disordered breathing such as snoring or sleep apnea. Older persons may suffer from pain due to arthritic or other medical prob- lems. In addition, psychological stress brought about by signifi cant life changes, such as the death of a loved one or moving, can inhibit sleep.

It is not a part of normal aging, however, for older persons to be sleepy and to feel the need to sleep during the day. Among the adaptations to age-related sleep changes is to maintain daytime activities with some exposure to fresh air, if possible. In addition, for people of all ages good sleep hygiene, which is discussed in Chapter 4, can go a long way towards regularly obtaining a good night’s sleep.

SUGGESTED RESOURCES

Center of Design for an Aging Society: http://www.centerofdesign.org The Center’s website provides guidance on designing homes, and modifying existing homes,

to maximize older adults’ health, wellness, and independence. Hearing Loss Association of America (HLAA): http://www.shhh.org HLAA provides assistance and resources for people with hearing loss and their families to

learn how to adjust to living with hearing loss. HLAA is working to eradicate the stigma associated with hearing loss and to raise public awareness about the need for prevention, treatment, and regular hearing screenings throughout life.

National Association for Continence: http://www.nafc.org This nonprofi t association’s goal is to de-stigmatize, promote prevention, and educate the

community about incontinence. It provides a national database for individuals seeking sup- port and diagnosis of incontinence and incontinence-related disorders.

National Eye Institute: http://www.nei.nih.gov Established by Congress in 1968 to protect and prolong the vision of the American people,

NEI’s research leads to sight-saving treatments, reduces visual impairment and blindness, and improves the quality of life for people of all ages.

National Heart, Lung, and Blood Institute (NHLBI): http://ww.nhlbi.nih.gov The NHLBI’s website has information on research, training, and education programs to pro-

mote the prevention and treatment of heart, lung, and blood diseases and enhance the health of all individuals so that they can live longer and more fulfi lling lives.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.centerofdesign.org

http://www.shhh.org

http://www.nafc.org

http://www.nei.nih.gov

http://ww.nhlbi.nih.gov

1CHAPTER

Health, Wellness, and Normal Aging

The learning objectives of this chapter include understanding

The value of proper nutrition, physical activity, and good sleep hygiene in the health of ■ older adults. Nutrition guidelines for older adults, as contained in ■ MyPlate for Older Adults, and how they differ from those for younger adults. The four vaccines that all older adults should have. ■ Basic screening tests for diseases and conditions that are preventable or for which there ■ is good prognosis if detected early. Key negative health behaviors to avoid to decrease the risks for chronic diseases. ■

SENIORS AGING HEALTHFULLY

When she turned 60, Pearl decided she wanted to stay healthy and active as long as possible. She was careful about what she ate. She became more physically active. Now she takes a long, brisk walk three or four times a week. In bad weather, she joins the mall walkers at the local shopping mall. When it’s nice outside, Pearl works in her garden. When she was younger, Pearl stopped smoking and started using a seatbelt. Now she’s using the Internet to fi nd healthy recipes. Last month, at the age of 84, she danced at her granddaughter’s wedding!

ENHANCING AND MAINTAINING HEALTH IN THE LATER YEARS

Life expectancy has risen dramatically in many countries around the world, including the United States. Simply being alive for more years, though, is not a particularly worthy achievement. When it comes to aging, everyone’s goal is to age in the best possible health.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

50 II. THE REALITIES OF GROWING OLDER

No one wants to live a long life in poor health, or in increasingly poorer health. Of course, to a large extent genetic make-up infl uences risks for different health conditions, and individuals have little or no control over many these risks. Common health problems, however, are strongly infl uenced by health behaviors, including those related to nutrition and physical activity, and health literacy. In addition, health behaviors affect the rate at which aging occurs and the quality of life that accompanies aging.

The majority (75%) of people 65 years of age and over who are not institutionalized rate their own health as good, very good, or excellent. Even among elders who are 85 years of age and over, more than 66% report good to excellent health (Older Americans 2010). Poor health is indeed experienced by many older adults, but clearly they are in the minority. Despite this fact, ageism and other factors result in many people assuming that aging is always accompanied by poor health.

Maintaining, and even enhancing, health and wellness is an active, lifelong process that requires awareness of one’s state of health and wellness, and continually learning and making changes to maximize it. Keep in mind, of course, that in order to engage in this lifelong process, opportunities for healthy choices and healthy living must be read- ily available. In addition, there are motivational factors that infl uence health and well- ness behaviors, which are discussed in the Practical Applications at the end of Part II of this textbook. Positive health behaviors are things to do to improve or maintain health, and negative health behaviors are things to avoid, or stop doing to improve or maintain health. Among positive health behaviors are eating nutritious foods, regularly engaging in physical exercise, and following a regular schedule for immunizations and screening tests. Among negative health behaviors are smoking, drinking excessive amounts of alco- hol, and tanning.

HEALTH PROMOTION

Health promotion and measures to prevent illnesses and health care problems are impor- tant at all ages of life. But younger people can get away with paying much less attention to positive health behaviors than can older people. As people age, neglecting their health begins to take its toll on them.

Nutrition

Good nutrition is important for everyone, but it is particularly important to older people. It directly relates to their health and wellness. Properly nourished older adults enjoy a higher quality of life, live longer, and have decreased disability, fewer infections, wounds that heal faster, fewer secondary medical complications, and shorter hospital stays than older adults who are undernourished (Challa, Sharkey, Chen, & Phillips, 2007). As researchers learn more about nutrition as well as the aging process, more information is becoming available about the unique nutritional needs of people as they age.

MyPlate for Older Adults

The fi rst food guide designed specifi cally for older adults was published by researchers at Tufts University in 1999 (Russell, Rasmussen, & Lichtenstein, 1999). The current guide, which has been updated to be consistent with MyPlate, the newest U.S. Department of Agriculture (USDA) food guide, is depicted in Figure 4.1 (“Scientists unveil MyPlate for Older Adults,” 2011). The guidelines for older adults differ from those aimed at the gen- eral adult population. For example, they include different forms of food that can have

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

4. HEALTH, WELLNESS, AND NORMAL AGING 51

advantages for older adults, such as frozen and canned fruits and vegetables, which can be easier to prepare and last longer than do fresh fruits and vegetables.

The guidelines for older adults also contain seven major recommendations for maximizing the value of nutritional intake to maintain or improve health (Lichtenstein, Rasmussen, Yu, Epstein, & Russell, 2008). The fi rst two recommendations are related: One is to reduce food consumption, thereby reducing calories, and the second is to eat nutrient-rich foods. As metabolism slows and energy needs decrease with age, the need for calories decreases. Women with relatively low physical activity may need only 1,600 calories per day, but women who are fairly active may need up to 2,200 calories per day. Comparable numbers of calories for men range from 2,000 to 2,800 calories per day. However, even though less food is needed, requirements for nutrients remain the same (except for iron in postmenopausal women). This means eating more foods that are high in a variety of nutrients and eating less fat, sugar, and refi ned foods. The third recommendation is to eat foods that are lower in fat and saturated fat.

The fourth recommendation is to eat foods high in fi ber. Fiber is found in foods from plants, so some ways to add fi ber to diets are eating cooked dry beans, peas, and lentils often; choosing whole fruit over fruit juice; eating whole-grain breads and cereals; and, leaving skins on fruits and vegetables, if possible. Eating more fi ber may prevent stomach or intestine problems, such as constipation, and it may also help lower cholesterol as well as blood sugar. It is better to get fi ber from food than dietary supplements. Increasing the amount of fi ber slowly helps to avoid unwanted gas.

The fi fth recommendation is to be aware of the potential need for supplements, in particular, calcium and vitamins D and B12. Both calcium and vitamin D are needed to

FIGURE 4.1 MyPlate for Older Adults.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

52 II. THE REALITIES OF GROWING OLDER

keep bones fracture free. Postmenopausal women need as much as 1,200 milligrams of calcium per day, and older men need 1,000 milligrams per day. No more than 500 mil- ligrams of calcium should be taken at one time because that is all the body can digest at once. Much research suggests that vitamin D is also very helpful in conjunction with calcium. Dowd and Stafford (2008), authors of the book, The Vitamin D Cure, contend that new research demonstrates that vitamin D helps the body protect against osteoporosis, high blood pressure, and cancer. Vitamin D defi ciency can lead to a variety of immuno- related diseases, fatigue, Seasonal Affective Disorder (SAD), and headaches. Also, aging skin does not make vitamin D as readily as younger skin does, so a vitamin D supplement may be in order. An adequate amount of vitamin D can be obtained by adults of all ages with a balance of sun exposure and supplements, while avoiding too much exposure. Ten to 15 minutes of exposure to the sun, several times a week, is probably adequate for most persons. Because of decreased gastric juices, it is recommended that those over 50 years of age take a vitamin B12 supplement to avoid the anemia and nerve damage that result from defi ciencies of this vitamin. Total vegetarians especially must supplement with B12 throughout their lives.

The sixth recommendation is to drink plenty of fl uids. With age, some of the sense of thirst is lost, so older adults should not wait until they feel thirsty. It is important for them to drink plenty of liquids such as water (several large glasses per day), juice, milk, and soup. Urine should be pale yellow. If it is a bright or dark yellow, more liquids need to be con- sumed. Seniors often stop drinking liquids in order to control their urine; however, health care professionals can give them much better ways to alleviate any problems of bladder control. Drinking plenty of liquids also helps fi ber move through the intestines. The sev- enth recommendation included with MyPlate for Older Adults is to be physically active.

In addition to these seven recommendations, there are two additional matters to pay attention to when it comes to seniors’ nutrition: One is protein and the other is anti- oxidants. Individuals need a bit more protein as they get older, 1.0 g/kg of weight rather than the 0.8 g/kg that they needed as younger adults. For example, an older person weighing 154 pounds (154/2.2 = 70 kg) should consume 70 g of protein per day. Four ounces of chicken, sirloin steak, ground beef, or canned tuna provide between 31 g and 35 g of protein; one cup of cooked lentils, lima beans, or kidney beans provides 16 g of pro- tein; and one cup of 2% cottage cheese provides 32 g of protein. Antioxidants are natural substances found in food that may help protect against some diseases. Antioxidants and common sources of them include beta carotene (dark orange and dark green fruits and vegetables), selenium (seafood, liver, meat, and grains), vitamin C (citrus fruits, peppers, tomatoes, and berries), and vitamin E (wheat germ; nuts; sesame seeds; and canola, olive, and peanut oils).

Specifi c quantities of nutrients for active 75-year-old men and women are listed in Table 4.1. Table 4.2 focuses on nutrients, listing recommended daily allowances (RDA), sources, and functions of nutrients.

Eating Well on a Tight Budget

For many seniors with limited budgets, it might take some thought and planning to be able to pay for the foods they should eat. Here are some suggestions. First, seniors can buy only the foods they need, planning meals and checking the supply of staples such as fl our and cereal prior to shopping. In case cooking or going out are not good options, having some canned or frozen food available is an alternative. Powdered, canned, or ultra-pasteurized milk in a shelf carton can be stored easily. Large packages of food can be shared with a friend. Frozen vegetables in bags save money because small amounts can be used and the rest can be kept frozen. If a package of meat or fresh produce is too C

op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

4. HEALTH, WELLNESS, AND NORMAL AGING 53

TABLE 4.1 Food Pattern Recommendations for Active 75-Year-Old Men and Women

WOMEN MEN

Energy 2,000 kcal 2,600 kcal

Grains 6 oz 9 oz

Vegetables 2.5 cups 3.5 cups

Fruits 2 cups 2 cups

Milk 3 cups 3 cups

Lean meat & beans 5.5 oz 6.5 oz

Oils 6 tsp 8 tsp

Discretionary calories 267 kcal 410 kcal

Source: Adapted from Lichtenstein et al. (2008).

large, a store employee may be able to repackage it in a smaller size. Other ways to keep food costs down include using store brands, which often cost less than name brands; planning meals around food that is on sale; and dividing leftovers into small servings, labeling, dating, and freezing them to use within a few months.

Funded through the federal Administration on Aging, in some communities, senior centers serve lunch up to 5 days a week at no cost to those age 60 and over. Low- or no- cost meals are also often available for older people at a community center, church, or school. This is a chance for seniors to eat good food and to be with other people. In some locales, home-delivered meals are available for those who are homebound. The federal Supplemental Nutrition Assistance Program (SNAP, formerly, the Food Stamp Program) helps people with low incomes buy groceries.

Nutrition Services

Adequate nutrition services for elderly people include screening, assessment, counseling, and therapy. All of these are important because even when older adults seem to know a lot about nutrition, their ability to use that information in making dietary choices is lim- ited (Hand, Antrim, & Crabtree, 1990).

Nutrition services can be provided to older adults through parts A and B of the Medicare program, the state Medicaid home- and community-based services waiver pro- gram, and the food programs of the federal Administration on Aging. Unfortunately, some individual local carriers for federal government programs may not pay for nutri- tion services. As a result, the very services that could help older people maintain their health, independence, and quality of life may not be available in some communities.

Physical Activity and Exercise

Regular exercise and physical activity are important to the physical, emotional, and men- tal health of almost everyone, including older adults. Being physically active can help seniors continue to do the things they enjoy and stay independent as they age. Regular physical activity over long periods of time can produce long-term health benefi ts. That’s why health experts say that older adults should be active every day to maintain their health. In addition, regular exercise and physical activity can reduce the risk of devel- oping some diseases and disabilities as people grow older. In some cases, exercise is an effective treatment for many chronic conditions. For example, studies show that people Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

54 II. THE REALITIES OF GROWING OLDER

TABLE 4.2 Nutrients: RDA, Sources, and Functions

NUTRIENT RDA (WOMEN—MEN)

SOURCES FUNCTIONS

Protein 1.0 g/kg nuts, legumes, fi sh, meat, eggs, dairy products

builds & repairs body tissues; aids nutrient transport, muscle contractions; energy source

Carbohydrates 130 g whole-grain breads & cereals, rice, pasta, beans, fruits, starchy vegetables

main source of fuel for heat and energy; keep intestinal tract healthy

Fats 15%–30% of calories

animal & vegetable oils, meat, cheese, butter, nonskim milk

provide energy; absorb some vitamins; insulate & cushion the body; add fl avor to food

Fiber 21–30 g soluble: oats, barley, beans, fruit and vegetables insoluble: corn, wheat bran, leafy green vegetables

soluble: lowers cholesterol; stabilizes blood glucose levels

insoluble: prevents constipation

Vitamins

A 700–900 mcg animal products, orange and yellow fruit & vegetables

maintains vision, skin, tissue health; aids new cell growth

B1 (thiamine) 1.1–1.2 mg whole and enriched grains, legumes, organ meats, leafy green vegetables

energy metabolism; aids proper function of nervous system;

prevents beriberi

B2 (ribofl avin) 1.1–1.3 mg whole and enriched grains, liver, dairy products

energy metabolism; building tissue; maintains good vision

B3 (niacin) 14–16 mg poultry, fi sh, meat, eggs dairy products, legumes

aids in proper digestion; skin & nerve functioning

B6 (pyridoxine) 1.5–1.7 mg whole grains, meat, fi sh, eggs, carrots

food digestion, metabolism, and absorption; boosts immune system;

brain & nerve function

B9 (Folate) 400 mcg (200 mcg folic

acid)

dark green leafy vegetables, legumes, liver, yeast

promotes normal digestion; essential for red blood cells; may reduce risk of heart disease

B12 (cobalamin)

2.4 mcg meat, liver, kidney, yogurt, dairy products, fi sh

builds proteins, red blood cells; aids nervous tissue function

C (ascorbic acid)

75–90 mg fresh vegetables & fruits antioxidant; infection resistance; aids collagen formation

D 10 mcg cheese, whole eggs, salmon, fortifi ed milk; sun

promotes calcium & phosphate use for healthy bones & teeth

E 15 mg vegetable oil, wheat germ, leafy green vegetables

protects red blood cells; preserves vitamins A & C

K 90–120 mcg leafy green vegetables, organ meats, cereals, dairy products

normal blood clotting; protein synthesis in plasma, bone, kidneys

Minerals

Calcium 1200 mg dairy products, salmon, sardines, broccoli, cabbage

healthy bones & teeth; normal blood clotting; nervous system

Magnesium 320–420 mg dairy products, meat, fi sh poultry, legumes

healthy bones & teeth; nervous system; energy metabolism

Potassium 4.7 g bananas, fresh & dried fruit, potatoes, broccoli, spinach

proper fl uid balance; muscle function

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

4. HEALTH, WELLNESS, AND NORMAL AGING 55

with arthritis, heart disease, or diabetes benefi t from regular exercise. Exercise also helps people with high blood pressure, balance problems, or diffi culties with walking.

Physical exercise of all kinds is helpful for older adults. Of course, it is critical that all seniors consult a health professional prior to beginning any exercise regime. Most older peo- ple do not have health problems that would prevent them from doing moderate activity or the types of exercises that can be benefi cial. In fact, there is a way for almost every older adult to exercise safely and get meaningful health benefi ts. Anyone who has been leading a mostly sedentary lifestyle, or who is not used to energetic activity, should approach exercise in a gradual way, increasing both the amount and the intensity to an optimal level over time.

According to results from the National Health Interview Survey, only 28% of men and 27% of women between the ages of 65 and 74 engage in regular, leisure-time physical activity (Schoenborn & Adams, 2010). The numbers do drop a little for those who are 75 or older, for men to 23%, and for women to 21%. Yet, there are so many ways to be active. For example, activity can be in short spurts throughout the day, or specifi c times can be set aside on specifi c days of the week to exercise. Many physical activities, such as brisk walking, raking leaves, or taking the stairs whenever possible, are free or low cost and do not require special equipment. Older adults can also check out an exercise video or DVD from their public library or use a fi tness center at their local senior center.

Both physical activity and exercise burn calories. Physical activities are activi- ties that get the body moving, such as gardening, walking the dog, raking leaves, and taking stairs instead of an elevator. Exercise is a form of physical activity that is spe- cifi cally planned, structured, and repetitive, such as weight training, tai chi, or aero- bics. Exercises generally fall into four main categories: endurance, strength, balance, and fl exibility. Some activities fi t into more than one of these categories. For example, many endurance activities also help build strength, and strength exercises can help improve balance.

Endurance, or aerobic, activities increase breathing and heart rate. These activities help people remain healthy, improve their fi tness, and help them to do their daily tasks. Endurance exercises improve the health of the heart, lungs, and cardiovascular system. They also delay or prevent many diseases that are more common in older adults, such as diabetes, colon and breast cancers, heart disease, and others. Physical activities that build endurance include brisk walking, dancing, jogging, swimming, biking, playing tennis, yard work (mowing, raking), and climbing stairs.

Even small increases in muscle strength can make a big difference in older adults’ ability to stay independent and accomplish everyday activities such as carrying groceries

NUTRIENT RDA (WOMEN—MEN)

SOURCES FUNCTIONS

Selenium 55 mcg kidney, liver, shellfi sh, brazil nuts

boosts immune system; maintains thyroid function

Zinc 8–11 mg meat, seafood, liver, eggs, milk, whole-grain products

cell reproduction; tissue growth and repair

Note: Lists of food sources are not exhaustive. B5 (pantothenic acid) is available in many different foods and is also produced by intestinal bacteria, so there are no known major defi ciencies of this vitamin. RDA has not been determined. Adequate intake is 5 mcg. B7 (biotin) is found in all foods, and thus defi ciencies are rare. RDA has not been determined. Adequate intake is 30 mcg. g = grams; mg = milligrams; mcg = micrograms; RDA = Recommended daily allowance (Where a range is given, the lower number is for women and the higher number is for men. RDAs are based on minimum requirements.)

Source: Adapted from USDA’s Food and Nutrition Information Center website; includes data from National Policy and Resource Center on Nutrition and Aging, Florida International University.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

56 II. THE REALITIES OF GROWING OLDER

and climbing stairs. Using weights to improve muscle strength is sometimes called strength training or resistance training. Strength exercises include lifting weights and using resis- tance bands to exercise. Balance exercises help prevent falls. Many lower body strength exercises, such as standing on one foot, as well as the popular tai chi, improve balance. Stretching can help one’s body to stay fl exible and limber, which provides more freedom of movement for regular physical activity as well as for everyday activities. Shoulder and upper-arm stretches, calf stretches, and yoga are all ways to improve fl exibility.

Physical exercise has also been shown to enhance mental ability and decrease depression. In fact, recent research indicates that physical exercise may be more important for mental abilities and mental health than are mental exercises (Wilcox et al., 2009).

Older adults talk about the advantages of regularly engaging in physical exercise in Video 6.

Mental Activity

The brain is an organ, and like all organs in the body, it needs to be used and exercised regularly. People who remain active by dancing (or any other type of physical activity), playing musical instruments, or engaging in focused games (e.g., scrabble, etc.) can reduce the probability of mental decline. Also, persons who become involved in groups such as civic organizations, church groups, social groups, athletic events, and so forth, seem to have less mental decline than those who are not so engaged. Social relationships are also important and seem to stimulate brain functioning. The old cliché, “use or lose it,” seems to be true in regard to the brain. Much more information about the role of mental activity is presented in Chapter 5.

Good Sleep Hygiene

It is important to get a good night’s sleep at all ages. Sleep provides the opportunity for the body to repair cell damage, it helps to prevent disease by refreshing the immune system, and it improves concentration and memory function. With age, it is harder to get quality sleep because physiological sleep patterns change, reducing periods of the most restful type of sleep, Rapid Eye Movement (REM) sleep. Nevertheless, daytime sleepi- ness is not a part of normal aging (Edwards et al., 2010). Therefore, it is especially impor- tant for older adults to practice good sleep hygiene. Good sleep hygiene includes the following elements:

Engaging in activities to keep energy level up during the day, preparing the body ■ for sleep at night; Etablishing a regular daily schedule of going to bed and rising; ■ Creating a comforting environment: a good mattress, pillow, and bedding; a ■ quiet, dark room with a suitable temperature and ventilation;

Episode 6: Senior Lifestyles

High Bandwidth:

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

aging/success_aging_6_large/grcc_player.html

Low Bandwidth:

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

aging/success_aging_6_small/grcc_player.html

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_6_large/grcc_player.html

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_6_large/grcc_player.html

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_6_small/grcc_player.html

4. HEALTH, WELLNESS, AND NORMAL AGING 57

Reserving the bed for sleeping, and sex, so it will be associated with only those ■ things; Developing a relaxing bedtime routine, such as taking a bath or listening to calm- ■ ing music; and, For periods of wakefulness during the night, trying to stay relaxed by engaging ■ in a repetitive, nonstimulating activity, such as counting sheep; and, if a wakeful- ness period extends to 15 minutes, getting out of bed and doing a quiet activity, keeping the lights dim.

Other tips for improving sleep include

Taking a daily walk, because exercise releases chemicals in the body that promote ■ restful sleep; Taking a 15- to 30-minute nap early in the afternoon, which can improve overall ■ restfulness; Getting 2 hours or more of sunlight a day because bright sunlight increases mela- ■ tonin, which regulates sleep–wake cycles; Combining sex and sleep because sex and physical intimacy, such as hugging ■ and massage, can lead to restful sleep; Limiting caffeine late in the day; ■ Eating no more than a light snack 3 hours prior to going to bed; ■ Limiting beverages within 90 minutes of bedtime; ■ Quiting smoking, or at least avoiding it within 3 hours of bedtime, because nico- ■ tine is a stimulant; Avoiding alcohol before bedtime—it may seem to aid sleep, but it actually causes ■ waking during the night; Blocking out snoring or other noises with earplugs or a white-noise machine; ■ Limiting use of sleeping aids and sleeping pills because many of them ■ have unpleasant side effects and thus are not a long-term solution to sleep problems; Reducing mental stress by jotting down worries or concerns, checking off tasks ■ completed on a to-do list, and listing goals for the next day, before retiring; and Using relaxation techniques, such as progressive relaxation or deep breathing, ■ which can prepare the body for sleep.

PREVENTIVE MEASURES

Preventive health measures include immunizations, screening tests, avoiding negative health behaviors, and health literacy. Medicare Part B covers a number of preventive ser- vices, for which there is no cost to Medicare enrollees. The topic of Medicare, including eligibility, what it covers, and what it costs, is discussed in Chapter 14.

Immunizations

Most older adults have heard that they should get a fl u shot every year, even if they do not all get one. They may not know that there are three other vaccines they should be sure to get—pneumococcal, shingles, and Tdap/Td (tetanus, diphtheria, and pertussis). Information on vaccinations is updated regularly on the website of the Centers for Disease Control and Prevention (www.cdc.gov).

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.cdc.gov

58 II. THE REALITIES OF GROWING OLDER

Infl uenza (Flu) Vaccine

Seniors are among those risk groups who can benefi t signifi cantly from being vaccinated against infl uenza (fl u). Every year, on average, 24,000 Americans die from the fl u and most of these deaths are among older adults. Although the proportion of older people being vaccinated has risen signifi cantly over the previous two decades, in 2008 only 67% had received a fl u shot within the previous 12 months. The goal of Healthy People 2020, which is for 90% of older adults to be vaccinated annually for the fl u, is not yet within reach, although annual fl u vaccinations are covered by Medicare.

Pneumococcal Vaccine

Pneumonia (pneumococcal disease), which can cause serious infections in the lungs, bloodstream, and the covering of the brain, is one of the leading reasons that seniors go to hospital emergency rooms. It is all too frequently also a cause of death for them. To avoid or minimize the effects of pneumonia, it is recommended that seniors receive a pneumonia vaccine once every 10 years. Until recently, very few seniors were receiving this vaccine. In 2010, compared to 65- to 74-year-olds, a higher proportion of adults age 75 and up had received at least one shot in their lifetime (54% and 66%, respectively). As is the case for fl u vaccination rates, racial and ethnic disparities in pneumonia vaccination rates still exist (Ward, Barnes, Freeman, & Schiller, 2011). The fact that pneumonia vaccinations are covered by Medicare increases the potential to achieve Health People 2020’s goal of 90% of seniors being vaccinated for the disease.

Shingles Vaccine

Shingles is a painful skin rash caused by the varicella zoster virus (VZV). As this virus is the same one that produces chicken pox, everyone who has had the chicken pox is at risk for getting shingles, because the virus remains in the body and then can become active again in the later years. About half a million Americans age 60 or older come down with shingles every year, and by the time they are 80, one out of two people will have had shingles (National Institute of Neurological Disorders and Stroke, 2011). Consequently, the CDC recommends that adults age 60 years or older receive the shingles vaccine, whether or not they recall having had chicken pox. Although shingles is not contagious, grandparents should be mindful of the fact that a person with active shingles can trans- mit the virus to a person who has never had chicken pox. Generally, Medicare Part D plans cover this vaccine.

Tdap/Td Vaccine

Tdap/Td is a vaccine that immunizes again tetanus, diphtheria, and pertussis. The vac- cine is recommended for older adults because vaccine-induced immunity seems to wane with age, and thinner skin can make them more vulnerable to wounds that would allow the tetanus bacteria into the body. Tetanus (“lockjaw”) is an acute bacterium that affects the central nervous system, causing tightening and spasms of muscles, particularly in the jaw, and fever and headaches. It may even result in death by suffocation. Diphtheria is an acute bacterial disease that affects the throat and skin, causing breathing problems, and potentially paralysis and heart failure. Pertussis (“whooping cough”) is an acute bacte- rium that affects the upper respiratory system. Symptoms include intense fi ts or spells of coughing, and a thick, sticky mucus in the throat, with the potential to cause pneumonia, Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

4. HEALTH, WELLNESS, AND NORMAL AGING 59

seizures, and brain damage. Diphtheria and pertussis are highly contagious, and both can result in death. These infections are easily passed on to babies who are too young to be vaccinated. Older adults should receive a Tdap vaccine, if they have not had one, and then a Td booster once every 10 years. The Tdap/Td vaccine is generally a Part D covered drug for Medicare patients.

Screening Tests

Screening tests are best for those diseases or chronic conditions that are accompanied by few or no symptoms but are preventable, or have good success rates from treatments when they are detected early. Recommendations for screening tests are regularly reviewed and can be found on the website of the U.S. Preventive Services Task Force (www.uspreventiveservicestaskforce.org/recommendations.htm).

Blood Pressure

Routine blood pressure measurement is recommended at least every 2 years for those with normal readings, and every year otherwise. Although individual differences abound, target rates are still 120/80 mm/HG, with the fi rst number (systolic pressure) being more important than the second (diastolic pressure) for adults over age 50. There are no symptoms of high blood pressure, but if uncontrolled, it can lead to a stroke, a heart attack, heart failure, or kidney failure.

Cholesterol

Cholesterol should be checked regularly, at least once every 5 years to estimate the risk of developing heart disease. A cholesterol level of 200 mg/dL is considered desirable. High blood cholesterol has been associated with heart disease, an increased risk of death from heart attacks, and hardening of the arteries (atherosclerosis).

Cancer Screenings

Research and advances in medical treatments have meant that many cancers that used to go undiagnosed and run their course quickly can now be detected early, leading to much better prognoses for recovery and longer lives despite cancer. An important key to the progress in this area is screening tests. Everyone over age 50 should be screened for colorectal cancer. Several different tests are available, and a health care provider can help determine which one may be best and when it should be given.

Women over age 40 should have a mammogram every 1 to 2 years for early detec- tion of breast cancer. Breast self-examination and regular physical breast exams by a health care provider are also essential parts of regular breast care. For early detection of precancer and cervical cancer, women should have a papanicolaou (Pap) smear every 1 to 3 years. Women who are older than 65 years of age with at least three recent normal Pap test results and no abnormal results in the previous 10 years do not need a Pap smear. Low-cost or free screenings are available to low-income, uninsured, and underin- sured women through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which is administered by the Centers for Disease Control and Prevention. In addition, Planned Parenthood offers low-cost Pap tests, and state and local health depart- ments can provide information on where affordable screenings are available. Medicare Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.uspreventiveservicestaskforce.org/recommendations.htm

60 II. THE REALITIES OF GROWING OLDER

covers one Pap test and pelvic exam every 2 years for women who are at low-risk for cervical cancer.

For men, Medicare provides for an annual prostate-specifi c antigen (PSA) test. A PSA-based screening has limitations and is still controversial, because it results in the detection of more cases of cancer, but small to no reduction in prostate cancer-specifi c mortality after 10 years. False-positive results in 12% to 13% of screened men result in unnecessary follow-up procedures and treatments that can be harmful. As a consequence, the U.S. Preventive Services Task Force has recommended that men age 75 and older should not be screened for prostate cancer, and younger men should discuss the benefi ts and harms of the PSA test with their clinicians before being tested (Lin, Croswell, Koenig, Lam, & Maltz, 2011). Researchers are studying ways to improve the PSA test and to fi nd other ways to detect prostate cancer early.

Blood Sugar

The American Diabetic Association recommends that all adults over age 45 be considered for diabetes screening by their health care provider every 3 years. Risk factors include high blood pressure and obesity.

Bone Density

Baseline bone density should be established prior to menopause, which occurs on aver- age around age 50. Postmenopausal women should be tested regularly to ensure that bone density does not dip into the range of T-scores that indicate osteoporosis. Although on average women lose 20% of bone mass in the fi rst 5 years following menopause, diet and exercise can maintain bone density loss at an acceptable, nonosteoporotic level. Routine screening can reduce the incidence of hip fractures and other effects of bone thinning.

Body Mass Index (BMI)

The best test for obesity is a BMI, a measure of body fat based on height and weight. Monitoring BMI and keeping it in check are important to reduce the sequelae of being overweight and obese, which include increased risks for heart disease and diabetes.

Sexual Health Screenings

Older adults should talk with their health care provider about being tested for sexually transmitted infections. Seniors will fi nd they need to be proactive in this area, because physicians often feel uncomfortable about discussing sexual matters with their older patients, and thus may avoid doing so.

HIV

Those at high risk for HIV should talk to their health care provider about screening. Conditions for high risk include having a blood transfusion between 1978 and 1985, being treated for sexually transmitted diseases, having unprotected sex with multiple partners, and having used injection drugs.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

4. HEALTH, WELLNESS, AND NORMAL AGING 61

Eye Examinations

A few serious conditions, such as macular degeneration, glaucoma, and retinopathy, which can all result in serious vision loss and even blindness, can develop more readily in older people (see the Medical Care chapter for information about these conditions). More common and more easily treated are presbyopia, dry eyes, and cataracts (which were discussed in the Physical Changes chapter). For the sake of both the serious and the more common eye conditions, a complete eye examination by a qualifi ed professional (e.g., ophthalmologist) is recommended for those older than age 45, and then follow-up examinations every 2 to 4 years thereafter.

Dental Checkups and Teeth Cleaning

Regular visits to the dentist will minimize tooth loss, as well as allow the dentist to check for oral cancers.

Depression

Depression is not a normal part of aging. Depression is associated with distress and suffering and can lead to impairments in physical, mental, and social functioning. The good news is that it is highly treatable. Older adults should talk with their health care provider about being screened for depression if they have felt down, sad, or hopeless over a period of 2 or more weeks, or have felt little interest or pleasure in doing things. Chapter 5 includes information on some treatment programs that have been proven to work well for older adults.

Avoiding Negative Health Behaviors

In addition to engaging in behaviors that enhance and maintain health, some behav- iors and habits should be avoided so that health is not compromised. Negative health behaviors that should be avoided or discontinued are smoking, overuse of alcohol, and tanning.

Smoking

The good news is that only 9.5% of older adults aged 65 years and older are current smok- ers, although many more used to be and, fortunately, have quit smoking. This rate com- pares favorably to the 20% to 25% of 18- to 64-year-olds who are current smokers (Older Americans 2010). In addition to being a primary cause of lung cancer and emphysema, cigarette smoking worsens the prognosis and symptoms of all chronic diseases. Among older people, the death rate for chronic lower respiratory diseases (the fourth leading cause of death among people age 65 and over) increased 50% between 1981 and 2006. This increase refl ects, in part, the effects of cigarette smoking. Smokers can do nothing better for their health than to quit smoking. There are many approaches to becoming a nonsmoker, and health professionals can help individuals choose one that can be helpful to them.

Part of the difference in longevity between various social–economic groups in the United States is related to the difference in the smoking rates between persons in these groups. Highly educated Americans have a 5.6% smoking rate. American adults ages 25 years and older with less than a high school education have a 28.5% smoking Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

62 II. THE REALITIES OF GROWING OLDER

rate (Centers for Disease Control and Prevention [CDC], 2010). A college education seems to promote healthy living, as there seems to be a clearer understanding of the devastating effects of using tobacco. In addition, there is probably a signifi cant differ- ence in peer pressure, given that smoking is increasingly stigmatized among college students.

Overuse of Alcohol

According to Schoenborn and Adams (2010), 12.5% of adults 65 years of age and older are considered moderate drinkers (3–7 drinks per week for women, 3–14 drinks for men) and 4% of older adults are considered heavier drinkers (more than 7 drinks per week for women, or more than 14 drinks per week for men. Age-related physi- ological changes increase the risks associated with alcohol. For example, compared to younger people, older adults have higher blood alcohol levels per amount consumed. Furthermore, 90% of older adults use medications, and as many as 100 of these medi- cations may interact adversely with alcohol. Chronic conditions, such as hypertension, gout, diabetes, insomnia, and depression, may be triggered or worsened by alcohol use.

Safe amounts and frequency for drinking are consuming on average of less than 1 drink per day, less than seven drinks per week, and less than three drinks on heavier drinking occasions. Drinking and using drugs that interact with alcohol should be avoided. No alcohol should be consumed if activities are planned that can be impaired by alcohol, for example, driving or caregiving for others. It takes about 1 hour for the body to metabolize one drink. Health professionals can provide counseling about safe drinking practices or advise on interventions for those at risk for alcohol abuse or dependence.

Tanning

Sun exposure at any age can cause skin cancer, as well as premature aging, immune suppression, eye damage, and allergic reactions (U.S. Food and Drug Administration [FDA], 2010). There are no safe ultraviolet (UV) rays and no safe suntans. During mid- day (10 a.m.–4 p.m.), when the sun is most severe, limiting direct sun exposure is a good. Except for the 10 to 15 minutes of sun that older people should get a few times a week to enhance their intake of vitamin D, it is recommended that skin be covered when in sunlight, or sunscreen lotion be used for protection from UVB solar radiation. The U.S. Food and Drug Administration (2010) also recommends that people should avoid artifi cial UV sources, such as tanning beds, entirely.

Health Literacy

Health literacy is the ability to locate and understand health-related information and services. It requires skills in the ability to search, comprehend, and use informa- tion from prose, and from charts and graphs, and the ability to identify and perform computations using numbers embedded in printed materials. Among the domains of health for which health literacy is important are information and services related to clinical health, prevention, and navigation of the health care system. Unfortunately, health literacy is quite poor at all ages. Among elderly people, health literacy is poor- est among the oldest-old, as can be seen in Figure 4.2.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

4. HEALTH, WELLNESS, AND NORMAL AGING 63

SUGGESTED RESOURCES

MedlinePlus: http://www.medlineplus.gov Health information from the National Library of Medicine and the National Institutes of

Health. NIHSeniorHealth: http://www.nihseniorhealth.gov An easy-to-use website that features basic health and wellness information for older adults

from the National Institutes of Health. Tufts University’s Human Nutrition Research Center on Aging: http://hnrc.tufts.edu The focus of this nutrition research center is on the needs of older adults. U.S. Food and Drug Administration: http://www.fda.gov/ForConsumers/ConsumerUpdates/

default.htm Consumer updates on dietary supplements, drugs, food, medical devices, nutrition, vac-

cines, pet products, and more.

50–64 65–74 Age Group

Below Basic

Basic

Intermediate

Proficient

75+

P er

ce nt

ag e

of R

es po

nd en

FIGURE 4.2 Health Literacy in Older Adults by Age Group.

Source: Adapted from Older Americans 2008: Key indicators of well-being. (2008). Special topic: Literacy table. Federal Interagency Forum on Aging-Related Statistics. Washington, DC: U.S. Government Printing Offi ce.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.medlineplus.gov

http://www.nihseniorhealth.gov

http://hnrc.tufts.edu

http://www.fda.gov/ForConsumers/ConsumerUpdates/default.htm

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

1CHAPTER

Mental Health and Mental Abilities

The learning objectives of this chapter include understanding

Positive mental health aspects of aging. ■ Treatments for mental health conditions, when they exist, can lead to signifi cant improve- ■ ments in older adults’ quality of life. The myth of inevitable decline in intellectual abilities with age. ■ The cognitive changes that accompany dementia and how they differ from normal ■ aging. The positive contributions that the creative arts can make to older adults’, and society’s, ■ quality of life. Factors that can positively or negatively affect older adults’ mental health and abilities. ■

Alice is 77 and is extremely active in her church. She chairs a committee on education, and she never misses a church function. She drives not only in town but several 100 miles to visit her children. She reads several magazines a week, is always reading a new book, is articulate in speech, and has a good memory. She lives independently and does her own cooking, shopping, and house cleaning. She is sought after by her friends and family for advice.

Harold is 68 and has been severely depressed since his wife died 2 years ago. He has isolated himself. He looks unkempt. He seems to have little interest in the affairs of the world or in anything else. He has insomnia, does not care to eat, has been losing weight, and cannot concentrate long enough to enjoy a book or even read the local newspaper.

Mary is 81 and is taking classes at the local community college. She is enjoying her classes and has a B average. She is articulate and speaks up in class. She relates well to the younger students and has a keen sense of humor. She complains that she is too old to remember all the material in the books and in the class notes, and then does as well or better than the younger students on her tests. She has learned to use computers and is extremely proud of her computer ability.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

66 II. THE REALITIES OF GROWING OLDER

MENTAL HEALTH AND MENTAL ABILITIES OF OLDER PEOPLE

Older people are the happiest people in America. How can this be? It defi es all the ste- reotypes about aging. After all, older people experience signifi cant losses in their lives, including physical changes to their own bodies, deaths of close friends, and the losses that accompany leaving the workforce. This seeming mismatch between the reality of older people’s lives and the stereotypes about them comes about because when thinking about aging, people most often focus on the negative things that can accompany it, while not noticing the positive ones. Of course, there are negative things that come along with aging, but negative things are experienced at every life stage.

One goal of this chapter is to present a more balanced view of aging. Some memory losses occur, but unless a person is beset by Alzheimer’s, these losses do not have to inter- fere with everyday life. For the previous several decades, we’ve been slowly uncovering more and more areas of life where older adults thrive and make contributions, not only to their own lives, but also to the lives of others. The creative arts is one of these areas that is discussed in this chapter.

MENTAL HEALTH

Now that we are beginning to look at more positive aspects of aging, we are discovering some facts about the lives of seniors that are surprising to many people. When it comes to discussing mental health and aging, much of the focus in research and in the media has been on mental health problems that are, in fact, not that common among older adults. In this section of Chapter 5, we begin with seniors’ overall sense of well-being and hap- piness. Seniors can become depressed, just as anyone can (except not usually young chil- dren), but they are less likely than are younger people to become so. Moving away from the stereotypes, we fi nd that there are specifi c treatments that work particularly well for older adults.

Psychological Well-Being and Happiness

What is known about adults’ general sense of well-being as they get older? Researchers Arthur Stone, Joan Schwartz, Joan Broderick, and Angus Deaton (2010) interviewed 340,847 people between the ages of 18 and 85 years about various aspects of psychologi- cal well-being. They found that global well-being follows a U-shaped pattern, with a high point in the youngest age group (18–21-year-olds), then a decline to the most negative ratings when people are in their early 50s, and an upward trend beginning in the late 50s through the oldest ages. Enjoyment and happiness show a modest increase into old age, again beginning when people are in their late 50s. Stress and anger, on the other hand, decline with age, and worry subsides after age 50.

Older adults’ may display more happiness than younger adults do because they ignore, overlook, or downplay negative information and situations (Mather, 2012). Their years of experience allow them to put negative events into perspective, resulting in their being able to take things in stride. In the 2010 National Health Interview Survey, 27,157 adults in the United States responded to a series of questions about their health, includ- ing questions about their mental health. Consistent with the fi ndings of Stone and his colleagues, the survey showed that, compared to young and middle-aged adults, people aged 65 and over were the least likely to report feeling sad or hopeless all or most of the time (see Figure 5.1; Schiller, Lucas, Ward, & Peregovy, 2012). As they age, adults improve their ability to regulate their emotions and become better at recognizing and focusing on those things that are more meaningful in their life, including close relationships Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

5. MENTAL HEALTH AND MENTAL ABILITIES 67

(Charles & Carstensen, 2010). This is another reason that seniors are likely to be happier than people who are their juniors.

Effects of Beliefs About Mental Health and Aging

Now well past the age of 60, rock musician Pete Townshend has a positive outlook on what it is like to be an older person. In 1965, though, when he was just 20 years old, he wrote My Generation, a song that included the lyrics, “Hope I die before I get old.” Using those lyrics in the title of a journal article, Heather Lacey, Dylan Smith, and Peter Ubel (2006) discuss how beliefs about well-being in old age can negatively affect both younger and older adults.

Beliefs about aging are important—if younger adults mispredict old age as miser- able, they may make risky decisions, not worrying about preserving themselves for what they predict will be an unhappy future. Conversely, exaggerating the joys of youth may lead to unwarranted nostalgia in older adults, interfering with their appreciation of current joys. (p. 168)

Clearly, the majority of older adults have positive feelings about their own well-being. Nevertheless, just like anyone else, older people do experience emotional lows and men- tal health problems, and when they are serious, diagnosis and treatment should be avail- able and encouraged. Perhaps a better understanding of depression can help us see how to avoid ageist stereotypes about mental health.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

18–44 45–64 65–74

Age

P er

ce nt

75+

Sadness

Hopelessness

FIGURE 5.1 Percentages of Adults With Feelings of Sadness and Hopelessness All or Most of The Time, United States, 2010.

Note: In separate questions, respondents were asked how often in the past 30 days they felt so sad that nothing could cheer them up, or so hopeless that nothing could cheer them up.

Source: Adapted from Schiller, Lucas, Ward, & Peregovy, 2012, Table 14, pp. 55–56.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

68 II. THE REALITIES OF GROWING OLDER

Depression

Depression is not a normal part of aging, but because of ageist stereotypes, a common myth is that older people are usually depressed. “Who wouldn’t be?” is what some peo- ple think when they dwell on the changes and losses that can accompany aging. A num- ber of helpful tips on adapting to some of these more common age-related changes are presented in the Practical Applications at the end of Part II of this textbook. Of course, older adults can become depressed, and when they do it is often a result of signifi cant losses in their lives—loss of a job and a decrease in income when they leave the paid workforce, deaths of their partner and friends, and loss of their home when they move to be near their children or grandchildren or to senior living communities. In addition, they may lose one or more of their children. People who in the past were respected because of their jobs, energy, and wisdom, often fi nd themselves disregarded in their later years. Some who have several of these losses amazingly still retain emotional stability and feelings of well-being. Others, however, become overwhelmed by their losses and need professional help.

Although depression is the most prevalent mental health problem among older adults (Centers for Disease Control and Prevention [CDC], 2009), the rate for them is lower than it is for any other age group: 6.1% for adults 55 years and over, compared to 10.2% for 18- to 24-year-olds; 8.3% for 25 to 34 and 35- to 44-year-olds; and 10.2% for 45- to 54-year-olds (Reeves et al., 2011). These rates are based on self-reports so they may underrepresent the problem in all the age groups. Rates are higher for elders in nursing homes and other residential settings.

Whatever its prevalence, depression is a serious mental health problem that is asso- ciated with feelings of despair, a denial of self-worth, and somatic symptoms, including loss of appetite, sleeping diffi culties, and fatigue. Older adults with depression use more medication, visit health care professionals and hospital emergency rooms more often, and if they enter the hospital, they stay longer (CDC, 2008). The vast majority of cases (as many as 80%) are highly treatable, so there is considerable hope for those who get profes- sional help.

Successful Depression Care Management for Older Adults

Three community-based programs have proven to be especially helpful for treating depression in older adults: IMPACT, PEARLS, and Healthy IDEAS (CDC, 2009). They all include the use of well-validated measures of depression; ongoing assessment to monitor the effectiveness of treatment and to make appropriate changes when the chosen treatment is found to be ineffective; and a depression care manager, who may be a nurse, social worker, psychologist, or other practitioner. In consultation with the primary care provider and the patient, the care manager delivers or facilitates the treatment plan, educates the patient, and keeps track of the patient’s progress. These programs have also been designed to help overcome one of the barriers to treatment for older people—their resistance to seeking and participating in mental health treatments. Many older people have very negative attitudes toward the mental health profession and so they are reluctant to seek help. Mental health stereotypes and stigmas and how to help overcome them are discussed further in the Practical Application at the end of Part II of this textbook.

In addition to these three effective treatment programs, prescription drugs can be part of the treatment process for many depressed persons. Currently, many drugs, if

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

5. MENTAL HEALTH AND MENTAL ABILITIES 69

adequately prescribed and used, can help people through diffi cult psychiatric condi- tions. For all treatment approaches, it is helpful when friends and family can provide

comfort to their loved ones who are depressed. Psychologist Michael Ryan talks about losses and depression in older adults and some strat- egies and treatments that can be helpful in Video 5.

Suicide

Although persons over age 65 comprise only about 13% of the U.S. population, 15.6% of suicides are among persons in this age group (American Association of Suicidology, 2010). The evidence seems clear that when older persons talk about suicide, they mean it. When they attempt suicide, they usually complete it. Men are much more likely to commit suicide at every age. In 2010, that was almost 6,000 suicides among those 65 years of age and older, 84% of which were male. Any older person talking about suicide should be taken seriously.

Many of the factors associated with depression are also associated with suicide. In fact, depression is often a precursor to suicide, so prevention and treatment for depression is considered to be pivotal in lowering suicide rates among older people. After reviewing the research literature on prevention programs, Sylvie Lapierre and her colleagues (2011) suggested several innovative strategies with the potential to be successful, among them turning patients’ focus to positive aging, engaging family members, using the Internet, and improving education on elderly suicide for health care providers. Clearly, much more work needs to be done to reduce the prevalence of suicide in the elderly.

Although our emphasis has been on deterring older people from committing sui- cide, there are some who believe that terminally ill patients should be able to access resources to end their lives legally. Two states, Oregon and Washington, have established assisted suicide laws for this purpose and you can learn more about them in Chapter 7.

MENTAL ABILITIES

Infants and children all begin to crawl, walk, and talk at about the same age. In fact, if they do not meet these developmental milestones “on time,” it is usually a sign of a prob- lem that needs to be addressed. In stark contrast to what happens at these early stages of development, adults become more and more different from one another as they age. This is one of the most common themes in the fi eld of aging, and the three scenarios at the beginning of this chapter exemplify this theme.

Such large individual differences among older people have challenged research- ers who seek to understand how mental processes develop into late life. On the one hand, some adults seem to reach their older years with mental abilities that are as good, and sometimes even better, than when they were younger. For others, mental abilities seem to decline as they age, even if they do not acquire a dementia such as Alzheimer’s disease.

Episode 5: Aging and Your Health

High Bandwidth:

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

aging/success_aging_5_large/grcc_player.html

Low Bandwidth:

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

aging/success_aging_5_small/grcc_player.html

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_5_large/grcc_player.html

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_5_small/grcc_player.html

70 II. THE REALITIES OF GROWING OLDER

Good News About Mental Abilities in the Later Years of Life

For years it was just assumed that as we grew older, the brain would deteriorate, lead- ing to a progressive and irreversible decline in mental abilities. Now it is known that, although the generation of new brain cells slows down in old age, it never ceases. Furthermore, physical and mental activity throughout life increase the potential for new cells to develop (Kempermann, 2009).

In general, researchers have found that some mental abilities do seem to decline with age, including speed of information processing—how quickly information is per- ceived and acted upon—and working memory—how much information can be actively maintained and manipulated in memory at one time. On the other hand, some mental abilities seem to be maintained, or even improve with age, including general knowledge and vocabulary. Timothy Salthouse is a psychologist who has conducted research on cognitive abilities in older adults for decades. Observing what he termed a “dramatic discrepancy” between how well seniors function in their everyday lives and their test scores on cognitive tests in the laboratories of research scientists, Dr. Salthouse (2010) has concluded:

People seldom need to perform at their maximum levels; effects of age likely vary across tasks or activities; there are large individual differences in the level of cog- nitive functioning at each age; cognition is not the only important factor associ- ated with success in most activities; increased age is often accompanied by greater amounts of experience, which may minimize negative consequences of declining abilities; and people may accommodate to declining abilities in a manner that could minimize any effects on real-world functioning. (p. 150)

Indeed, we are learning that people who are happy, who feel better about their abilities, and who have good social support usually do much better on challenging mental tasks.

Cross-Sectional and Longitudinal Studies

Most studies of mental abilities use cross-sectional research methods. In cross-sectional studies, two or more groups of people defi ned by age are tested at a given period in time. For example, in Table 5.1, each of the columns for the year of study (2010, 2020, and 2030) represents possible cross-sectional groups. These groups, consisting of people in different age categories, may have had very different life experiences, so that results of these cross- sectional studies are infl uenced not only by the age of the people, but also by the cohort, or generation, in which they were born. In longitudinal studies, the same person is tested over a period of time (usually years). For example, in Table 5.1, each of the rows for the year of birth (1950, 1970, and 1990) represents possible longitudinal groups. Longitudinal studies can reveal changes over time in individuals, but they have their own diffi culties,

TABLE 5.1 Cross-Sectional and Longitudinal Research Variables

YEAR OF BIRTH YEAR OF STUDY

2010 2020 2030

1950 60-yr-olds 70-yr-olds 80-yr-olds

1970 40-yr-olds 50-yr-olds 60-yr-olds

1990 20-yr-olds 30-yr-olds 40-yr-olds

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

5. MENTAL HEALTH AND MENTAL ABILITIES 71

including the fact that people are tested repeatedly, which also may affect the results. Few longitudinal studies of mental abilities exist, because they are much more diffi cult to carry out; abilities of interest, as well as how they are measured, change over time; and they are much more costly.

Memory and Aging

One of the most studied mental abilities is memory. Human memory is fallible and peo- ple are generally bothered when they forget. Concerns about memory loss increase with age, especially because it is the most well-known symptom of Alzheimer’s. Myths about memory and aging abound in our society, and belief in these myths has been shown to affect memory performance in older adults (Levy, Zonderman, Slade, & Ferrucci, 2012).

A common myth about memory is that the best memory is one in which nothing is ever forgotten. However, there are signifi cant pitfalls of having a so-called perfect mem- ory. Luria (1968) described one man who had such an exact memory for people that he could not recognize them if they changed their clothing or had a different haircut. There are also some things that no one wants to remember—all their old phone numbers, for example.

Yet, forgetting important things is not good, and high levels of forgetting are usu- ally a symptom of a problem, ranging from stress to dementia. So, memory strategies are valuable because when effectively applied, they make it possible to remember important things that might otherwise be forgotten. Adopting strategies to remember events indi- cates a high level of cognitive functioning, and profi cient use of memory strategies is a sign of good cognitive management skills.

In research comparing the use of memory strategies by young and older adults, the young adults are almost always in college, where they have ongoing opportunities to learn and practice strategies for remembering. Most of the older adults, who were in school during the 1950s or earlier, learned only one strategy for remembering—rote rehearsal, that is, repeating things over and over. Rote rehearsal by itself is not a good memory technique because it does not help to establish long-term remembering. In fact, it was not until the 1960s that a signifi cant body of experimental evidence began to dem- onstrate the positive effects of categorizing strategies on recall of verbal materials. These important historical facts about the development of thinking about memory strategies must be recognized as critical factors in affecting the kinds of strategies that many of today’s older adults will tend to use when faced with a task requiring memory (Sugar, 2007). Older adults even reject as valuable those strategies, such as categorizing and grouping, that are particularly effective for learning and remembering, and instead often regard them as “cheating.” In the absence of being in school, engaging in intellectually challenging activities with a high memory demand, such as chess, may provide oppor- tunities during later adulthood to continue to exercise the mental capacities required to learn and practice memory strategies.

Too often, fears of family members and friends about an older loved one’s perceived forgetfulness lead to premature, or unnecessary, institutionalization. Concerns about a steam iron being left on or bills not being paid on time can worry older adults as well as their families and friends. Appropriate instruction in using memory strategies and mod- ern technology, however, can do much to alleviate these fears—for example, using lists and reminder notes to remember to carry out important actions in everyday life and to prevent memory failures that could jeopardize safety. New products and services furnish other means for reducing concerns about older adults’ personal vulnerability, such as steam irons that shut off after a short period of not being used and automatic bill paying services. With all the new technology, there are many applications that already exist, and C op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

72 II. THE REALITIES OF GROWING OLDER

many more that could be designed, to help everyone, regardless of their age, to remember the important things in their lives.

Cognitive Health: The Healthy Brain Initiative

Rather than focusing on abilities that might wane as we get older, researchers and health professionals have begun to look at opportunities to maintain and even improve cogni- tive health. Recognized only recently as an important issue for the public health system, cognitive health

can be viewed along a continuum—from optimal functioning to mild cognitive impairment to severe dementia . . . and cognitive health should be respected for its multidimensional nature and embraced for the positive changes that occur as a natural part of the aging process . . . components of healthy cognitive functioning include: language, thought, memory, executive function (the ability to plan and carry out tasks), judgment, attention, perception, remembered skills such as driv- ing, and the ability to live a purposeful life. (CDC, 2011, p. 7)

In 2007, the Centers for Disease Control launched The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health. The initiative has three purposes: to fi nd out what is already known about cognitive health, to investigate gaps in knowl- edge, and to determine how public health can contribute to cognitive health (CDC, 2011). Sadly, despite its name, most of the effort on this initiative has been invested in studying and assessing cognitive impairment, determining needs and services related to it, and developing state dementia action plans.

Alzheimer’s Disease and Other Dementias

Although people at every age regularly forget things, and there may be more forgetting and more to forget as we age, those who develop dementia show progressively more and more forgetting that eventually affects their day-to-day living. Dementia, which means “absence of mind” (from Latin, de- “without,” and ment “mind”), is used to describe more than 70 disorders that with one thing in common—a loss of brain function resulting from progressive, degenerative damage to neurons (nerve cells) in the brain. It affects memory, thinking, language, judgment, and emotional behavior, eventually affecting daily func- tioning and leading to death.

The most common type of dementia, accounting for approximately 80% of cases, is Alzheimer’s disease, which was fi rst described by a German physician, Alois Alzheimer, in 1906. It is the sixth leading cause of death among adult Americans. Other common types of dementia are vascular (poststroke) dementia and Pick’s disease (Alzheimer’s Association, 2012). Changes that occur in the brain with most types of dementia are not reversible. However, sometimes dementia can be reversed, or at least stopped, if the cause is diagnosed soon enough, and if it is related to low vitamin B12 levels; changes in blood sugar, sodium, or calcium levels; hypothyroidism; chronic drug abuse; a brain tumor; or, the use of certain medications (such as some cholesterol-lowering drugs).

Causes of Alzheimer’s

Many avenues of research have been explored to determine what causes Alzheimer’s. One hypothesis is gaining support from basic research on the immune system, and on neuroinfl ammation in particular. According to this hypothesis, Alzheimer’s begins with C

op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

5. MENTAL HEALTH AND MENTAL ABILITIES 73

neuronal stress, from sources such as infections, traumatic brain injury, and genetic vari- ations in protein alleles. Neuronal stress increases the production of proinfl ammatory cytokines, including beta-amyloid precurser proteins, which are thought to bring about the increased density of plaques and tangles in the brains of Alzheimer’s patients (Griffi n, 2011).

Researchers are concluding that Alzheimer’s “should be designated as a syndrome rather than a disease” because it is “heterogeneous with regard to age of symptoms’ onset, pattern and mix of clinical features, neuropathology, expression of markers, comorbid conditions, response to treatment, risk factors, and genetics/family history” (Hampel, Lista, & Khachaturian, 2012, p. 326). Clinically, the progression of Alzheimer’s seems to be unique in each person.

Some individuals decline rapidly in the initial phases, but then reach a plateau for awhile, and even show occasional glimmers of improvement, before they lapse into further deterioration. Others may decline more slowly in the early stages, but then degenerate more quickly toward the end. Every individual does not suffer the same symptoms during the course of the disease or suffer them at the same time or to a similar degree. (Andreae, 1992, p. 61)

Diagnosis and Treatment of Alzheimer’s

Memory problems are the most well known indication of Alzheimer’s, but there are other signs, too. The Alzheimer’s Association (2012) notes 10 signs to be aware of, which are listed in Table 5.2. It can be diffi cult to distinguish these signs from changes that may occur with normal aging, so Table 5.2 includes brief descriptions of them, too.

TABLE 5.2 Comparing Signs of Alzheimer’s With Typical Age-Related Changes

ALZHEIMER’S TYPICAL AGE-RELATED CHANGE

Memory loss that disrupts daily life. Sometimes forget names or appointments, but remember them later.

Challenges in planning or solving problems. Sometimes make errors when balancing a checkbook.

Diffi culty completing familiar tasks. Occasionally needing help to use settings on a microwave or to record a TV show.

Confusion with time or place. Getting confused about the day of the week but fi guring it out later.

Trouble understanding visual images and spatial relationships.

Vision changes related to cataracts.

New problems with words in speaking or writing. Sometimes having trouble fi nding the right word.

Misplacing things and losing the ability to retrace steps.

Misplacing things from time to time and retracing steps to fi nd them.

Decreased or poor judgment. Making a bad decision once in a while.

Withdrawal from work or social activities. Sometimes feeling weary of work, family, and social obligations.

Changes in mood and personality. Developing very specifi c ways of doing things and becoming irritable when a routine is disrupted.

Note: Information in Table 5.2 is from the Alzheimer’s Association website (www.alz.org).C op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

http://www.alz.org

74 II. THE REALITIES OF GROWING OLDER

A common approach for diagnosing Alzheimer’s has been to administer a combina- tion of neuropsychological and neurological tests, the latter often directed at eliminating other conditions, such as strokes, tumors, or other neurological diseases. The Mini-Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975), which primarily measures memory and orientation to place and time, is the most frequently used neuropsycho- logical test. This approach works reasonably well once cognitive and behavioral signs are obvious. However, it is believed that changes in the brain begin long before such signs are readily observed (Alzheimer’s Association, 2012).

New approaches for detecting Alzheimer’s in its earlier stages are beginning to pro- duce encouraging results. Biomarkers of amyloid-beta protein deposits can be obtained through cerebrospinal fl uid and a PET scan, and biomarkers of neurodegeneration can be obtained through cerebrospinal fl uid, a PET scan, and an MRI. Once a comprehensive assessment of cognitive function indicates probable Alzheimer’s, these biomarkers can lead to a reasonably defi nitive diagnosis. Even so, confi rmation of Alzheimer’s is still only achieved through examining the brain after the patient has died because the char- acteristic neurofi brillary and amyloid pathologies and loss of synapses can be readily observed then.

The U.S. Food and Drug Administration has approved several prescription drugs that can improve symptoms of Alzheimer’s, although they do not change the course of the disease (Alzheimer’s Disease Medications, 2008/2012). For mild to moderate Alzheimer’s, three cholinesterase inhibitors have been shown to lead to a temporary improvement in memory function: donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). These drugs stop the action of acetylcholinesterase, which is overabundant in Alzheimer’s patients and which degrades acetylcholine, a neurotransmitter associated with learning. For moderate to severe Alzheimer’s, memantine (Namenda) may be helpful. This drug protects brain cells from the damage caused by an excess of the chemical, glutamate, which is brought on by Alzheimer’s.

Although no cure is yet in sight, actively managing Alzheimer’s can signifi cantly improve the quality of life of patients and their caregivers.

Active management includes: (1) appropriate use of available treatment options, (2) effective management of coexisting conditions, (3) coordination of care among physicians, other health care professionals and lay caregivers, (4) participation in activities and adult day care programs, and (5) taking part in support groups and supportive services such as counseling. (Alzheimer’s Association, 2012, p. 136)

The Probability of Getting Alzheimer’s

There is disagreement as to how many people have Alzheimer’s disease in the general population. The most common current estimate is 5 million Americans. More women than men are affected because they live longer than men do. The rate is very low for people under age 65. However, after age 65, there seems to be a continual increase in the prevalence of Alzheimer’s. There is speculation that after age 85 the prevalence may increase substantially, perhaps reaching as high as 50%. However, a comprehen- sive study of over 1,000 people aged 85 and older in one community, including those in institutional care, found just 12% with moderate or severe cognitive impairment, and an estimated additional 7% with undiagnosed dementia (Collerton et al., 2009). Furthermore, in 2009, of 1.8 million deaths among Americans 65 years of age and older, Alzheimer’s was listed as a cause of death just 4.3% of the time (Kochanek, Xu, Murphy, Miniño, & Kung, 2011). Although it is likely that Alzheimer’s often goes undiagnosed, and is likely underreported as a cause of death, taken together these data suggest that C

op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

5. MENTAL HEALTH AND MENTAL ABILITIES 75

the prevalence of Alzheimer’s, especially after age 85, is much lower than some have speculated.

A small percentage of cases of Alzheimer’s (1% to 2%) occur prior to age 65. Accordingly, these cases are termed early-onset and, different from most late-onset cases, they appear to have a hereditary component. Mutations in three genes—amyloid precur- sor protein gene (APP), presenilin 1 gene (PSEN1), and presenilin 2 gene (PSEN2)—seem to be responsible for this type of Alzheimer’s (Rogaeva, 2002).

Impact of Alzheimer’s on Families

Alzheimer’s is often referred to as a family disease, because all members of the family are affected by it—emotionally, socially, and fi nancially. As the disease progresses, families are forced to give more and more time to caring for their loved one because they cannot be left alone. If they wander away, they may not be able to fi nd their way back. They often have strange sleep schedules and disrupt their caregiver’s sleep. Eventually, they will need constant care for feeding and toileting.

On average, once diagnosed with Alzheimer’s, a person lives approximately 4 to 8 years, but this varies substantially depending on how soon it is diagnosed. Some individu- als live 20 years or longer with the disease (Alzheimer’s Association, 2012). Support groups can bolster caregivers emotionally, and offer practical suggestions, as well as opportuni- ties to exchange information about community resources. More information about the

value of support groups is discussed in Chapter 12. Supporting family care- givers helps them to keep their loved one at home as long as possible, with demonstrated health ben- efi ts for patients and care- givers alike, and fi nancial benefi ts that surpass the cost of support programs (Habermann, Cooper,

Katona, & Livingston, 2009). For further information about the effects of Alzheimer’s dis- ease on the brain and caring for those with Alzheimer’s, watch Video 8.

A National Plan to Address Alzheimer’s

In 2007, the Alzheimer’s Association and thousands of individual citizens began advocat- ing for a national strategy to combat the disease. Their work culminated in the National Alzheimer’s Project Act (NAPA), which was signed into law by President Barack Obama in January 2011 to coordinate research and services; improve diagnosis, treatments, and outcomes; and work with countries around the world to combat Alzheimer’s and related dementias. Accordingly, a National Plan to Address Alzheimer’s Disease has been developed (U.S. Department of Health and Human Services, 2012). The fi ve goals of the plan are:

To prevent and effectively treat Alzheimer’s disease by 2025; ■ To enhance care quality and effi ciency; ■ To expand supports for people with Alzheimer’s disease and their families; ■ To enhance public awareness and engagement; ■ To improve data collection and analysis to track progress on the plan. ■

Episode 8: Aging and Alzheimer’s

High Bandwidth:

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

aging/success_aging_8_large/grcc_player.html

Low Bandwidth:

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_

aging/success_aging_8_small/grcc_player.html

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_8_large/grcc_player.html

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_8_small/grcc_player.html

http://raidercast.grcc.edu/flash/2011_2012/grcctv/successful_aging/success_aging_8_large/grcc_player.html

76 II. THE REALITIES OF GROWING OLDER

Accompanied by additional funding for research, public education, and support for people with Alzheimer’s and their families, the National Alzheimer’s Project and the National Plan have the potential to change the trajectory of Alzheimer’s in the United States and around the world.

Creativity and Aging

When people think about mental abilities and aging, they do not usually think about creativity. Two aspects of creativity are of particular interest when it comes to aging. One is the extent to which creative ability is infl uenced by age, and the other is the extent to which participation in the creative arts can positively affect older adults’, and others’, quality of life.

Creativity has often been thought of as a domain of the young. Research over the last two decades, however, indicates otherwise. David Galenson (2010), a pioneer in the economics of creativity, examined the careers of renowned painters, sculptors, poets, novelists, and movie directors, using a variety of measures to characterize an artist’s best work. His research led him to categorize important artists into two types—experimental innovators, such as Paul Cézanne, who seem to be most creative in their later years, and conceptual innovators, such as Pablo Picasso, who seem to be most creative when they are young.

Experimental innovators seek to record their perceptions. They work tentatively, by trial and errors . . . . They consider making art a process of searching, in which they wish to make discoveries in the course of executing their works. They build their skills gradually, and their innovations appear incrementally in a body of work. In contrast, conceptual innovators use their art to express ideas or emotions. Their innovations are conspicuous, transgressive, and often irreverent. These inno- vations appear suddenly, as a new idea produces a result different not only from other artists’ work, but also from the artist’s own previous work. (Galenson, 2010, pp. 354–355)

Based on his own research as well as that of others, psychologist Dean Simonton (1990) has concluded that there are many reasons to be optimistic about creative potential in the later years:

Those who are creative when they are young continue to be so in late life, though ■ the quantity of their work may decrease; Older people can, and do, overcome physically disabling conditions to continue ■ their creative work; Some people are late bloomers; and ■ There can be a resurgence of creativity at the end of life. ■

There are many ways to express creativity—through performance arts, such as music, theater, and dance, as well as creative writing and the visual arts. Different from the crafts that are often a component of senior center activities, the arts “engage the mind, body, and emotions, sparking curiosity, problem solving, and artistic accomplishment” (Patterson & Perlstein, 2011, p. 28). In other words, engaging in the arts is a complex cog- nitive activity.

In order to evaluate the potential positive effects of participating in the arts, the late Gene Cohen and his colleagues (Cohen et al., 2006) conducted a study comparing older adults who were recruited to participate in a chorale group (the intervention group) with Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

5. MENTAL HEALTH AND MENTAL ABILITIES 77

older adults in a comparison group. A total of 166 people with an average age of 79 years were in the study. Chorale members attended professionally conducted rehearsals once a week for 30 weeks and gave several public performances over the course of a year. At the end of 12 months, relative to the comparison group, the chorale group members reported improvements in their overall health, fewer physician visits, fewer falls, and higher morale. Cohen and his fellow researchers concluded that, “we have witnessed true health promotion and prevention effects . . . achieved through sustained involvement in a high-quality participatory art program—in this case, in an ongoing chorale directed by a professional conductor” (p. 733).

In 2012, the National Academy of Sciences convened a workshop “to identify research gaps and opportunities to foster greater investment in promising arts-related research that can seed interventions to improve quality of life for older adults” (Kent & Li, 2013, p. 1). Among the outcomes of the workshop were calls for research to evaluate the effects of arts programs across the lifespan; to compare the effects of different art forms, individually, and in combination; to broaden the diversity of people involved in the studies; and to examine the results of changing from a familiar art form to something new. New technologies are making it possible both to conduct and evaluate all kinds of programs, and arts interventions are no exception.

A pioneer in studying creativity and aging, Gene Cohen (2000), stated:

The importance of understanding creativity in relation to aging is profound, because doing so will not only enable older people to have access to their potential in later life, but it will also challenge younger age groups to think about what is possible in their later years in a different way. (pp. 5–6)

POSITIVE AND NEGATIVE INFUENCES ON MENTAL HEALTH AND MENTAL ABILITIES

Our mental health and mental abilities are infl uenced by many factors: physical, mental, and social activities; medical conditions; medications; and nutrition, among others. Some are very well-known, others less so, and we are learning more about yet others every day. Attention to these factors can help us maintain good cognitive function and indicate when it is time to seek medical attention.

Use It or Lose It: The Role of Physical, Mental, and Social Activities

Physical exercise is as important as, or more important than, mental exercise for retain- ing intellectual abilities. Physical exercise brings oxygen and increases blood fl ow to the brain, helping to maintain intellectual abilities, in part by stimulating the growth of new brain cells. Then mental exercise can ensure their survival.

The brain is an organ, and like all organs in the body, it needs to be used and exer- cised regularly. The old cliché “use it or lose it” seems to be true when it comes to the brain. Remaining mentally active helps people to maintain their mental abilities. Mental activity may include challenging tasks such as playing chess, doing crossword puzzles, and learning to play new pieces of music, and also participating in civic organizations, church activities, and social groups. And, researchers have concluded that educational programs can also improve cognitive functioning among older adults (Zelinski, Dalton, & Hindin, 2011). The gains from educational and training programs, however, can be Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

78 II. THE REALITIES OF GROWING OLDER

expected to be lost if those who participate in the programs return to nonstimulating environments or fail to exercise the skills they have learned.

Medical Conditions

Chronic illness can also affect a person’s mental health. Congestive heart failure, for exam- ple, can cause a loss of oxygen that can lead to abnormal brain functioning. The tremen- dous fatigue caused by congestive heart failure can lead to depression. Diabetes can lead to impotence in men, resulting in a damaged self-image, depression, and irritability. In addition, severe diabetes in either men or women can result in signifi cant mood swings, depending upon their blood sugar levels. The pain that accompanies arthritis can lead to fatigue and result in irritability and depression. Chronic conditions, including high blood pressure, cardiovascular disease, and diabetes, have also all been linked to lower cogni- tive functioning among older adults. Even young and middle-aged adults can experience the reduced cognitive abilities associated with these conditions (Schaie, 2011).

Medications

As might be expected, misuse of medications can have deleterious effects on mental health. Instructions for taking medications can be diffi cult to read and understand, lead- ing patients to take too little or too much medication. When older people take drugs that are helping them, it is not uncommon for them to share even their prescription drugs with a friend who may have similar health problems. Still others, because of limited resources, take only a few of their prescribed drugs, trying to save money.

In most clinic trials, over-the-counter and prescription drugs are tested in isolation so we know relatively little about the effects of taking several different medications simul- taneously. Yet, as we learn in Chapter 14, older adults often take fi ve or more prescription drugs per week. One of the authors worked with a senior citizens’ center director who had a woman attending her neighborhood center who was lucid, energetic, and a great helper. Over a period of 3 months, the helper became increasingly confused and irritable. The director began to think she might need to be placed in a nursing facility. One day the center director, upon visiting her home, found 21 different prescriptions from fi ve differ- ent physicians. The woman had not told each physician that she was also going to others. Among the prescriptions, the director found psychotropic drugs (major mood changers), such as chlorpromazine and diazepam, and a host of other drugs for numerous physical ailments. Because of the medications, the woman had deteriorated mentally to the point where she was not only mixing the drugs in dangerous combinations, but was taking them in quantities that would make most individuals act irrationally. The happy outcome of this story is that the woman was taken off most of the drugs, put under the supervision of one physician, and recovered her mental and emotional health. When one works with older persons and mood or mental changes take place, it is important to inquire about the medi- cations they are taking. Health care professionals need to be informed about others who might be treating a person, just as elderly patients should be apprised about side effects that drugs might have on their moods or mental condition.

Nutrition

Inadequate nutrition can cause changes in mental health. For example, low levels of vitamin B12 can lead to mood changes, depression, and symptoms of dementia, such as memory loss. Often persons living alone do not cook or eat wholesome meals. As a result, Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

5. MENTAL HEALTH AND MENTAL ABILITIES 79

they do not get the vitamins, minerals, or protein that their bodies need. Persons working with the elderly need to be aware of the eating habits of their clients. Inadequate nutrition over a period of time can have a negative impact on mental health.

THE MYTH OF INEVITABLE DECLINE

Just as physical abilities change with aging, so do mental abilities. Nevertheless, we know that much of what has been believed about older adults’ mental health and mental abilities is overly negative, or just plain wrong. We also know that many factors have an impact, and maintenance, and even improvements, in mental functioning can occur throughout the lifespan. There is much to learn within this area of aging, but one thing we know for certain is that it is never too late to begin a new endeavor, be it physical, mental, or social.

SUGGESTED RESOURCES

American Psychological Association, Offi ce on Aging: http://www.apa.org/pi/aging/ This website offers information specifi c to mental health for older adults. It features webi-

nars, book suggestions, research, services, and programs, with recommendations for how to deal with mental health issues.

Dementia Advocacy and Support Network (DASN): http://www.dasninternational.org/ DASN is an international network of organized by and for those diagnosed with dementia.

Educational materials about dementia and resources and strategies for living positively with dementia are provided through the organization’s website.

National Center for Creative Aging (NCCA): http://www.creativeaging.org Formed in 2001, the Center’s mission is to explore the connections between creative expres-

sion and healthy aging and to maximize opportunities for people to participate in the cre- ative arts. The website has links to research, publications, programs, events, news, and blogs all focused on creativity and aging.

National Institute on Aging, Alzheimer’s Disease Education & Referral Center (ADEAR): http:// www.nia.nih.gov/Alzheimers/

This website provides referrals and information for people interested in Alzheimer’s. It fea- tures new research, and a scientifi c understanding of the disease.

SharpBrains: http://www.sharpbrains.com SharpBrains is a for-profi t business that collects data and provides evaluations for consumers

about the growing market in “brain fi tness” tools and products.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.apa.org/pi/aging/

http://www.dasninternational.org/

http://www.creativeaging.org

http://www.nia.nih.gov/Alzheimers/

http://www.sharpbrains.com

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

1CHAPTER

Sexuality and Aging

The learning objectives of this chapter include understanding

Sexuality in the context of aging in the 21st century. ■ Sexuality and aging in a second sexual revolution. ■ Sexuality as a normal and vital part of life at any age—even old age. ■ The factors that inhibit sexuality including physical limitations, cultural considerations, ■ menopause, and prescription drugs. A new paradigm for sexuality and aging that focuses on relationships, prevention of HIV/ ■ AIDS, and practices (some specifi c) that can enhance sexuality.

JANE AND CARL: EVER ACTIVE

Jane and Carl are both 67 and have a vigorous, active sexual life. Throughout their marriage, they have been sexually active. They see sex not only as a period of intimacy, but also as a fun, creative, and fulfi lling process. Neither Jane nor Carl smoke; their drinking is moderate. They exercise regularly, are in great physical condition, and have a zest for life. Jane went through menopause without many physiological or psychological problems. Their three children were out of the home by the time Jane completed the menopausal process. Her gynecologist gave her some strategic information that enhanced her sex life.

DORIS AND BEN: BORED AND TIRED

Doris is 73. Ben is 76. They have rarely had sexual intercourse during the last 10 years. Doris went through menopause at the age of 54, rather late for most women. At the time she was going through menopause, the last of her six children left home. She had been a full-time house- wife and mother, and most of her self-image revolved around her children. She never had a great

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

82 II. THE REALITIES OF GROWING OLDER

deal of communication with her husband, who worked at two jobs to support his large family. After menopause Doris went into a period of depression, which her very religious husband found diffi cult to understand. He became angry at her lack of sexual responsiveness during her periods of depression. After menopause sexual intercourse became increasingly painful. In her earlier years, she always found sex rather perfunctory. There was a repetitive sameness in their sex life that even Ben began to fi nd less than stimulating. As a result, their sexual activi- ties decreased markedly, a decrease that Doris found acceptable. Ben, always a heavy smoker, had diffi culty after age 50 obtaining and maintaining an erection. He fantasized about sex and periodically masturbated; increasingly as he got older, he was ready to ignore their sexual life. In their late 60s, they began to sleep in separate bedrooms, and eventually they ceased most sexual activities.

SEXUALITY: AN INTEGRAL PART OF LIFE

Sexuality is best viewed in the context of relationships, attitudes, and values. It involves more than reproductive systems and genitalia; it is more than the hormonal system. Sexuality is an attempt to gain intimacy, to have warmth, and closeness. It is a physical and psychological closeness that is part of human necessity. With that in mind, sexuality is seen as much more than just sexual contact. It includes an embrace, mutual stimulation, a touch, a couple holding hands on their daily walk.

Unfortunately, in the past, older people were thought to have no interest in sexu- ality. The elderly were seen as prudish, asexual people. It was almost as if eventually everyone was expected to lose sexual desire and any interest in the erotic or the sensual. Added to this was the emphasis within our youth culture of relating things erotic to the young, to the perfect bodies of the late adolescent or young adult. Sexual desire, it has been thought, might last through middle age at a signifi cantly reduced level, but surely would disappear in later life.

Research, however, increasingly indicates that older people are sensual, have real needs for closeness and intimacy, and are involved in continuing sexual activities of vari- ous types. Whether by intercourse, masturbation, mutual masturbation, or other means, the vast majority of older people are still sexually active. Among happily married older people, most still fi nd the sexual side of their relationships important. About two thirds of unmarried older persons, even those over the age of 70, are sexually active. Although they may fi nd sex less intense than when they were young, many older people experience tender and satisfying sexual experiences.

A Second Sexual Revolution

No topic lends itself so well to the concept of a new paradigm of aging than sexuality and aging. Once perceived as asexual or sexless, many older people have challenged old stereotypes and myths regarding sexual attitudes and practices. But these liber- ating attitudes and practices obviously do not apply to all older people. Some old myths and taboos still prevail among some subgroups of the elderly. But with the inclusion of Baby Boomers into the older ages—the generation that pioneered the gender and sexual revolutions—there is a continuing redefi ning of sexuality and aging.

The story is told of an 18-year-old young woman in 1964—among the fi rst of the Baby Boomers—who visited three gynecologists in her small Midwestern town in which she lived before she found one who would prescribe the newly available birth control pill because she was unmarried (Jacoby, 2005). These pills changed the sex lives of a Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

6. SEXUALITY AND AGING 83

whole generation, and they led to the sexual revolution of the 1960s and 1970s. “The pill” changed the thinking of Baby Boomers in the 1960s by making young women feel that they had the right to enjoy sex without fear of pregnancy (Jacoby, 2005). And now, over 40 years later with another pill (actually multiple pills that treat erectile dysfunction [ED]), along with changing attitudes and sexual practices, Baby Boomers are creating a second sexual revolution. And, this sexual revolution will change forever the way people think about sex and aging. This is a revolution in spirit and attitude about sexuality in midlife (and beyond), and at its core is the belief that many physical problems should be treated and overcome rather than be thought of as a normal part of growing older (Jacoby, 2005). With this social revolution occurring in America brought about by the increasing size of the older population, it is important to view sexuality as an integral part of the whole life span—into the oldest ages.

A NEW PARADIGM FOR SEXUALITY AND AGING

In spite of some changes to sexual function for older men and women, progressive older people, as well as aging Baby Boomers, feel that sex can still be an integral part of life— now and into their later years. In order to realize this goal, in addition to the newer medi- cal approaches to enhance sexuality, new sexual attitudes and practices are emerging. This is in spite of the reality that “senior sexuality still ruffl es some feathers in a society that prefers not to acknowledge its existence” (Golden, 2004, p. 3). Indeed, it is reported that many physicians will not even raise the issue of sexuality with their older patients. Dr. Robert Butler said, “What affection is subject to ridicule seems just wrong, ageist” (Golden, 2004, p. 3). (Dr. Butler originally developed the term ageism to describe prejudice against the elderly.)

Medical Interventions to Improve Sexual Functioning

Research has demonstrated that the production of the male sex hormone testos- terone—which occurs in both sexes—drops and consequently can result in lowered interest in sexual activities. Some physicians prescribe testosterone as a libido booster for women who are diagnosed “low-T.” It is often given in the form of a testosterone patch. However, some experts warn that this treatment could have only a limited effect because female sexual libido is tied to emotions, stresses, and other factors that no one patch or pill can treat (Klein, 2004). When Viagra was developed to treat ED in men, many women wanted something similar to enhance their sexuality. Low sexual desire, inability to become aroused, lack of orgasm, or painful intercourse can occur at any age but become more common with age. Among the many factors that can contribute to these problems are inhibitions, anxiety, insuffi cient lubrication or stimulation, and pre- vious sexual trauma or abuse, as well as hormonal changes, chronic health conditions, and medications.

Enhancing Female Sexuality in Aging

Some experts have cautioned that biological treatments for women (including tes- tosterone) can sometimes have only limited effects because female sexual response is related to multiple factors. In its report on testosterone treatment for men and women, the Consumer Reports on Health pointed out that measuring testosterone is ineffective for women because the tests are really not accurate and normal levels have not been established (“Healthy Sex: His and Hers,” 2006). In fact, this report went on Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

84 II. THE REALITIES OF GROWING OLDER

to state that women should not use testosterone if they have had uterine or breast cancer, heart disease, or liver disease because of the dangers of exacerbating disease processes.

Hormone-Replacement Therapy

In the past, hormone-replacement therapy (HRT) was widely used to treat the symp- toms associated with menopause including sexual dysfunction. In the summer of 2002, however, a major longitudinal study—the Women’s Health Initiative—was halted when it became clear that HRT actually increased the risk of breast cancer and heart disease (Noonan, 2003). More recently, estrogen is sometimes being combined with testosterone in a product called Estratest, which is the only testosterone application approved for women in the United States (“Healthy Sex: His and Hers,” 2006). Nevertheless, this prod- uct can cause the reduction of HDL, the “good” cholesterol. In addition, for women who wish to try estrogen for vaginal dryness and reduced clitoral sensitivity, some creams such as Estrace and Premarin are available along with vaginal inserts such as Estring that allow smaller and safer doses. Short-term use of low-dose estrogen patches or pills are sometimes used for women who are not at high risk for heart disease or breast cancer (“Healthy Sex: His and Hers,” 2006).

Viagra and Female Sexuality

Although sildenafi l (Viagra) may improve clitoral sensitivity in a small minority of women, many physicians and researchers warn that there is no good reason for women to try these types of drugs that that were developed to treat ED in men (“Healthy Sex: His and Hers,” 2006). Instead, simply reducing coronary risk factors may improve clito- ral sensitivity, and prolonging foreplay and using nonpetroleum lubricants (such as K-Y Jelly and Replens) can increase vaginal moisture. It is also claimed that remaining sexu- ally active may promote vaginal moisture. Combining these approaches with treating issues that impair the libido may improve a woman’s ability to achieve orgasm. In sum- mary, a combination of steps can be used to enhance the sexual functioning of women. These include treating underlying medical disorders, adjusting dosages, or substituting drugs for underlying medical conditions, reducing stress, and/or dealing with problems in relationships with the help of a marriage counselor or a sex therapist who focuses on sexual attitudes and practices.

Enhancing Male Sexuality in Aging

As indicated earlier in this chapter, one of the biggest breakthroughs in promoting sexual functioning in aging males was the development of sildenafi l (Viagra), and the related drugs tadalafi l (Cialis) and vardonafi l (Levitra), all of which can be used to treat ED—insuffi cient penile erection. ED is typically the result of physical problems, often ones that relate to heart disease, although anxiety can be the cause. These three drugs (Cialis, Levitra, and Viagra) dilate blood vessels in the penis, enabling increased blood fl ow, which leads to an erection. Tadalafi l lasts about 36 hours, while the others last about 4 hours. The 36-hour pill is designed for men who want spontaneity in sexual activities. It is advised that before a man begins treatment with any of these three drugs, he should have his vision and heart examined because of potential negative side effects (“Healthy Sex: His and Hers,” 2006).Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

6. SEXUALITY AND AGING 85

Other Benefi ts of Treating Male ED

A major fi nding of an AARP sexual survey—surprising to many—is the increased plea- sure these treatments for men have given their female partners (Jacoby, 2005). This is directly contrary to the old myth that older women do not enjoy sex. Another myth dis- pelled by this survey is that the main reason men take these new medications is to have sex with younger women. In reality, most of these men want to continue to have sex with their older spouses or partners, and the women in the survey (of all age groups) reported that their own sexual satisfaction was improved by their partners’ use of these drugs. Jennifer Berman, MD, a leading sex researcher and counselor, said that the notion that “older women are just happy to be done with sex” is based on cultural stereotypes that equate women’s sexual desire—and desirability—with a youthful body (Jacoby, 2005, p. 57). Dr. Berman went on to say that for every older woman who comes to her offi ce complaining that her husband wants too much sex, there is another older woman who complains that she wants sex, but that her husband has no interest. “This woman can be 30 or she can be 70,” according to Berman (Jacoby, 2005, p. 57).

Testosterone Replacement

Testosterone replacement therapy (TRT) became the “hot” hormone therapy of choice for hundreds of thousands of men in the early years of the 21st century (Noonan, 2003). This treatment was believed by many middle- and older-aged men to treat sexual dysfunc- tions—such as ED and loss of libido that some have termed andropause, the male version of menopause in women. But while a man produces less testosterone as he ages, most men remain within normal limits, unlike the major shutdown of hormone production that women face in menopause, according to Stanley Slater at the National Institute on Aging (NIA; Greider, 2003). Slater stated that many people incorrectly blame lowered tes- tosterone for male sexual problems in middle and later life. In the vast majority of cases, he said, erectile diffi culties in men are due to circulatory problems.

TRT has also been credited with improving memory and bones, building vitality, and enhancing sexual desire. But Slater indicated these claims are not necessarily true. Only a small number of men—younger men with damaged pituitary glands or testes— may be helped by this therapy. Slater seriously questioned the value and safety of TRT for healthy older men. He went on to state that “testosterone feeds the growth of tumors in men who have metastatic prostate cancer,” noting that most older men have inactive and harmless “nests” of cancer cells (Greider, 2003, p. 16).

Other studies have indicated that supplemental testosterone may trigger excessive red blood cell production, which can thicken the blood and increase the risk of a stroke. In 2002, the NIH (National Institutes of Health) cancelled a major large-scale trial related to testosterone because of questions of the study’s design and the opposition of the direc- tor of the National Cancer Institute due to concerns about potentially increasing prostate cancer (Greider, 2003). In addition, the answer to the question of what is “normal” for tes- tosterone levels varies greatly. It is tricky to measure hormone levels in men because the tests can be fi ckle, the results varying depending on when they are administered—times of day, seasons—and levels of exercise.

Growth Hormone

Another hormone treatment for men that is very controversial is the growth hormone dehydroepiandrosterone (DHEA). In fact, the reservations about using DHEA are dou- ble those for using testosterone because of its safety hazards. In addition, in its dietary Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

86 II. THE REALITIES OF GROWING OLDER

supplement formats, DHEA is mostly unregulated. As a result, labeled dosages are ques- tionable and the use of this potent hormone is not likely to be monitored by a physician (“Healthy Sex: His and Hers,” 2006). Instead, physicians and researchers of Consumer Reports on Health advise avoiding DHEA entirely.

High Blood Pressure and Sexuality

As hypertension (high blood pressure) is fairly widespread among older people—women and men—it is important to treat this condition to prevent strokes, heart disease, kidney failure, and the risk of ED. According to The Harvard Men’s Health Watch,

men with hypertension are four times more likely to develop erectile dysfunction than men with normal blood pressures. High blood pressure contributes to erectile dysfunction in the same way it causes to strokes and heart attacks, by damaging blood vessels. Erections depend on a six-fold increase in the amount of blood in the penis, and that requires healthy arteries to let the blood in and healthy veins to keep it there. (“High Blood Pressure,” 2003, p. 4)

Therefore, for healthy sexual functioning, it is important to control blood pressure because some medications for hypertension actually contribute to ED. Most often, this is related to the thiazide diuretics category of drugs. As a result, ED caused by some medications can sometimes be treated by switching to other blood pressure drugs (“High Blood Pressure” 2003).

Psychological Factors in Sexuality

Some couples drift into sexual apathy because of unresolved anger. They attempt to “get at” their partner by refusing sexual activity or signifi cantly reducing the amount or type of sexual contact. This can happen to couples at any age. Unfortunately, too many older people assume that their reduced sexual contact is simply the result of growing older. As a result, they do not obtain the type of counseling that would enable them to resolve their feelings of anger and once again become sexually active partners.

Depression can also be a major factor in the loss of sexual desire. Depression can also occur at any age; it is a major factor in sexual dysfunction at all ages. Unfortunately, once again, the older the person, the higher the probability that he or she will assume that sexual dysfunction is the result of physical factors due to aging, and thus will not seek the help that could rejuvenate his or her sexual life. In instances where there is no physical basis for the loss of sexual desire, professional counseling can be helpful. A competent counselor can assist in understanding the factors and processes that lead to a loss of sexual desire. An effective counselor can also be helpful in recovering sexual drive.

Sex and Health

Experts point out that sexual satisfaction is not just for personal pleasure. Dr. Julia Heiman, Director of the Kinsey Institute for Research in Sex, Gender, and Reproduction at Indiana University, pointed out that a satisfying sex life can promote good emotional and physical health. In addition, sex itself may have direct health benefi ts. Orgasm or any loving touch may result in the body releasing substances that can ease pain, improve immunity, and elevate mood long after the immediate pleasure of sex. It is contended that people who have strong, intimate relationships are more likely to experience fewer Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

6. SEXUALITY AND AGING 87

chronic diseases and more likely to live longer (“Healthy Sex: His and Hers,” 2006). As a result, there are important reasons to look into and address any signifi cant loss of sexual interest and functioning in all ages of life.

RELATIONSHIPS AND SEXUALITY

Personal relationships are integral to understanding sexuality in the older ages, whether they are between partners who are married or cohabiting or single individuals.

Older Couples

Many years ago, Robert Atchley (1991) indicated that couplehood for older people has four basic functions: (a) intimacy, (b) sexual intimacy, (c) interdependence, and (d) belong- ing. In some ways, all of these relate to sexuality in older adults even though not all of them focus directly on sexual activities. They all contribute to feelings of closeness, being needed, and having someone to turn to in all aspects of life.

As they grow older, couples ideally develop an ability to anticipate each other’s sexual needs. With years of experience, they can acquire the ability to fulfi ll those needs. They may develop a reciprocity of sexual responses that comes only after years of interac- tion. Many decades ago, Masters and Johnson (1970a, 1970b) indicated that two persons committed to each other in a loving relationship can learn to give sexual pleasure to each other as they communicate their sexual preferences in an atmosphere of trust and accep- tance. With the passing years, many learn how to articulate and listen in the interplay of sexual recreation and desire.

Postmenopausal Women

For some postmenopausal heterosexual women, the realization that they will no longer get pregnant liberates them sexually. In addition, many postmenopausal women become liberated from inhibitions that kept them from a free expression of their sexual desires. With no worries about kids opening their bedroom doors while engaged in sexual activi- ties, older couples have fewer reasons to be uptight about sex. In addition, they tend to be better able to please each other, knowing where and how to arouse sexual feel- ings and pleasures (Golden, 2004). In fact, some sex counselors have seen quite a bit of what anthropologist Margaret Mead termed PMZ (postmenopausal zest). “Indeed, some women begin to have orgasms for the fi rst time as they grow older,” according to the late Dr. Robert Butler and the late Myrna Lewis, his wife, (he was a leading gerontologist and geriatrician, and she was a psychotherapist) in their book, The New Love and Sex After 60 (Golden, 2004, p. 1).

Strains in Older Marriages

A survey by AARP of Baby Boomers as well as people in their late 60s, 70s, 80s, and older, found that a majority of those questioned said that a satisfying sex life was important to a person’s quality of life. But for most, it was not the number one priority. Rather, good spirits, good health, close ties with friends and family, fi nancial security, spiritual well- being, and good relationships with a partner were all rated higher than good sex (Jacoby, 2005).

Indeed, men put a higher priority on sex than women did in the survey. Some 66% of men compared to 48% of women stated that good sex was important to their quality Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

88 II. THE REALITIES OF GROWING OLDER

of life. By age 60, the gender gap on the value of good sex widens with 62% of the men versus 27% of the women putting a high priority on satisfying sex. But some experts fi nd these statistics misleading because so many older women no longer have partners. The AARP survey found that nearly one third of the older women and men with partners described their sex life somewhere between “yawn” and “bloody awful.” Yet 63% of the men and women with partners described themselves as either “extremely satisfi ed” or “somewhat satisfi ed” with their sex lives (Jacoby, 2005, p. 58).

The late Helen Gurley Brown, founding editor of Cosmopolitan magazine, stated, “When people say they can’t have sex because of a bad back or arthritis or things that can affect our bodies, I think they’re really looking for an excuse not to have sex” (Jacoby, 2005, p. 82). What is needed is the ability to negotiate sexual issues and problems that are related to age in order to develop or maintain strong relationships.

Marriage and Frequency of Sex

Researchers in Britain surveyed people in 59 countries for a report in the medical jour- nal, The Lancet, and found that married people in every country engaged in more sexual activities than did single persons with the ratio between married and singles as high as 9 to 1 (Moore, 2006). The differences in sexual activity were evident in both the industrial- ized nations as well as those in the developing world.

The question can be raised as to where do all the stereotypes of sexless marriages come from? A Canadian researcher and therapist stated that many people in the Western world have vague ideas as to how much sex is appropriate. He went on to point out that there is a great myth that the single life is the most active, with sexual encounters almost every day (Moore, 2006). But in regard to the four industrialized countries studied—Aus- tralia, Britain, France, and the United States—more than 80% of married people reported that they recently had sex compared to only 50% to 60% of singles.

Romantic/Passionate/Companionate Love

An analysis of 25 studies involving over 6,000 people in short- and long-term relationships focused on fi nding different levels of satisfaction (Acevedo & Aron, 2009). This analysis, reported by researchers at Stony Brook University, differentiated between three kinds of love: romantic love—being able to retain “intensity, engagement, and sexual interest” for both short-term and long-term relationships (p. 59); passionate love—romantic love with “high obsession, uncertainty, and anxiety” (p. 63); and companionate love—“a warm, less intense love, devoid of attraction and sexual desire” (p. 59). The researchers concluded that “contrary to what has been widely believed, long-term romantic love . . . appears to be a real phenomenon that may be enhancing to individuals’ lives—positively associated with marital satisfaction, mental health, and overall well-being” (p. 64).

Single Older Women

Single older women cannot be stereotyped. Words such as lonely, shy, or insecure no longer apply. Nearly half of the single women in the AARP survey reported that, as singles, they were happier than they had ever been in their lives. But given the opportunity, many of the single women said they would be open to a committed relationship (Mahoney, 2006). This survey, entitled, “Lifestyles, Dating and Romance: A Study of Midlife Singles,” found that 31% of single women aged 40 through 69 were already in an exclusive relationship, and another 32% were dating nonexclusively. But about 10% had no desire to date at all, Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

6. SEXUALITY AND AGING 89

with another 14% willing to date if the right man came along, but they were not really trying very hard to fi nd such a person. The remaining 13% in this survey said they were actively looking for a mate (Mahoney, 2006).

Gail Sheehy, a contributing editor at Vanity Fair magazine and author of the bestsell- ing book, Passages, as well as a more recent book, Sex and the Seasoned Woman, points out that 75% of divorced older women have a serious relationship after divorce (Longcore, 2006). To obtain the data for her book on older women and sex, Sheehy posted a ques- tionnaire on her website about sex and romance and followed that up by meeting with groups of women across America. Her fi ndings dispel two myths: (a) that women are not interested in sex after menopause, and (b) that there are no good men out there for these women. Among women aged late 40s to their mid-80s, some 20%, a group Sheehy terms seekers, “are hungry for sex” and have not given up on fi nding a new relationship (Longcore, 2006, p. E1). And one third of the single women in her surveyed groups were dating younger men. Sheehy points out, as have others, that older women will likely spend more time unmarried than married, yet they have been largely ignored in many sex studies. The drive to love is one of the most powerful human drives, yet, Sheehy says, there is a persistent gap between cultural beliefs about sex and private sexual behavior.

Dating Younger Men

Sheehy found that the reason single older women date younger men is because men their own age are typically looking for traditional wives with the same roles that these women played in their child-rearing years. The women surveyed in Sheehy’s groups said they played these roles for 25 years. Now they want to be an equal life partner, not a caretaker, and they want time for themselves. Today’s older single women, Sheehy says, are inter- esting, accomplished, and independent. Older men tend to be intimidated by all these attributes, whereas younger men are not. In the new sexual paradigm, older women no longer have to wait to be contacted by men; they can take the initiative to contact men. Primarily this has been brought about by online dating services, and online connections such as chat rooms, Facebook, and so forth. The Internet has brought about a whole new era in developing relationships of all kinds. There are even online dating services geared specifi cally for older adults, OurTime.com and SeniorPeopleMeet.com being two of them. Sheehy summed up her research by stating that, “continuing interest and pleasure in sexuality is very much a part of the senior years” (Longcore, 2006, p. E2).

THE PREDOMINANCE OF BEING SINGLE

Surveys indicate that over half (57%) of adult Americans live single lives (“Single life in vogue for 51% of women,” 2007). And, married couples have become a minority of all households for the fi rst time in modern American history. In 1950, only 35% of American women were living without a spouse.

The reasons for these two new realities fall on both ends of the age spectrum. At younger ages, women are marrying later or they are living with unmarried partners in greater numbers for longer periods of time. In older ages, women are living longer as widows, and after divorces, women are more likely than men to delay remarriage.

As a result, it is estimated that American women are likely to spend more years of their lives as single persons than as part of a couple with a partner, according to Bella De Paulo, professor at the University of California, Santa Barbara, and author of a book on single people. She says that “the reality is relationships are now what happens between longer periods of singleness” (Mahoney, 2006, p. 50).

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

90 II. THE REALITIES OF GROWING OLDER

In addition, there are ethnic and racial differences in marriage rates. About 30% of Black American women live with a spouse compared to 49% for Hispanic women, 55% for non-Hispanic White women, and more than 60% of Asian women, according to the Census Bureau (“Single Life in Vogue For 51% of Women,” 2007). It is estimated that the only times in American history that single living was so widespread were during major wars, such as World War II, and when Black American couples were separated by slavery.

Sex and Personal Values

Even though physical intimacy in sexual relationships is vital to many older people, it can be in direct confl ict with the value systems they have lived with all their lives. This can result in mixed feelings on the part of some older people as well as attempts to hide their behavior from friends and families. Still, not too many unmarried couples want to marry their dating partners. Some are not willing to give up their independence. Others say they do not have the same reasons for marriage that younger people do, such as starting a new life and beginning a new family. Others are fearful of deteriorating health; they do not want to become caregivers for sick spouses. Many older couples do not marry because of fi nancial considerations, including possible loss of pensions or Social Security incomes, complex estate provisions, and inheritances for children.

OLDER LESBIAN, GAY, BISEXUAL, AND TRANSGENDER PEOPLE

Not much is known about the physical or mental health and social service needs of older self-identifi ed lesbians, gay men, bisexuals, and transgender individuals even in the fi rst decade of the 21st century.

Historical Context

In order to begin to understand the lives of older homosexuals, it is important to briefl y look at the history through which they lived. For much of the 20th century, homosexual- ity was linked to mental illness and criminality. In some ways, this is ironic because up until the early 1900s, for example, lesbianism was looked at as rather harmless. Indeed, some homosexual activity actually was thought to prepare young women for “real sex,” meaning sex with men (Clunis, Fredrikson-Goldsen, Freeman, & Nystrom, 2005). The term Boston marriage was used to defi ne the long-term relationships women developed and maintained with other women leading into their older ages. These lesbian relation- ships were often given respectability because the women were generally well educated and fi nancially secure, and thus not considered social or economic burdens to their fami- lies (Clunis et al., 2005).

On the other hand, after 1910, societal views toward lesbianism changed dramati- cally because of the medicalization of this form of sexuality and the negative publicity it received. Increased newspaper coverage of the dangers of lesbianism, along with police raids on bars and clubs catering to gays and lesbians, became common in bringing atten- tion to America’s supposed homosexual threat as perceived at that time. Indeed, homo- sexuality was classifi ed as a disease by the American Psychiatric Association until 1973, which is why the term medicalization of homosexuality is used.

Attitudes and actions toward gays and lesbians varied throughout the 20th cen- tury, but for the most part, focused on the notions that these folks were perverse and predatory. As a result, laws were passed and enforced that criminalized homosexuals and Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

6. SEXUALITY AND AGING 91

ultimately drove them underground (Clunis et al., 2005). It was believed that the “illness” of homosexuality could be “cured” by psychiatrists or mental health workers. Freudian and other forms of analysis, which could go on for years, and insulin shock therapy were often used to combat lesbianism in female adolescents. Electroconvulsive shock therapy (ECT) was also employed when other approaches did not work. In some cases, lobotomy, a surgical procedure performed on the brain, was also used (Clunis et al., 2005).

To avoid being caught up in the criminal laws and mental health codes targeting them, many homosexuals simply married members of the opposite sex. Estimates vary, but it is thought that about 40% of lesbians have been married to men at some time in their lives, with some 25% to 33% having children (Barker, 2003). The reasons cited for getting married included (a) not recognizing their lesbianism, (b) doing what was expected of them, (c) suppressing lesbian desires, and (d) marrying because of being pregnant or wanting to have children (Clunis et al., 2005). In addition, many homosexuals were pres- sured into heterosexual marriage by their psychiatrists or their churches.

Changing Times

Finally, beginning with the sexual revolutions of the 1960s, the visibility and plight of the nation’s sexual minorities—lesbians, gays, bisexuals, and transgender people—began to change. Some of the milestones in the advance of sexual minority visibility over the last few decades include the Stonewall riots (rioting over homosexual rights), the civil rights movement, the feminist movement, the coming of gay and lesbian “pride” parades and celebrations in cities across America, unisex clothing fashions, the HIV/AIDS epidemic, and more recently, legalized same-sex marriage in some parts of the country.

The ages at which homosexuals recognize and/or declare their homosexuality var- ies. Older lesbians discover, or disclose, their sexual orientation at various ages including adolescence, early adulthood, and middle and older ages. They may also “come out” after a heterosexual marriage or in retirement (Barker, 2003).

Although long-term romantic partner relationships vary among lesbians, this type of relationship tends to be the most sought after by middle- and older-age lesbians (Weinstock, 2003). Indeed, it is estimated that many, if not most, adult lesbians want to grow old with a partner. Lesbians typically move through courtship with the object of establishing permanent relationships. And increasingly, these relationships involve chil- dren (Weinstock, 2003).

Older gay men have also experienced coming out at various ages. Some older gay men marry women when they are young adults but discover their homosexuality later in their lives. Others acquire male partners earlier in life and live in marriage-like unions with them most of their lives. Still others stay single and have short-term relationships with multiple male partners or brief sexual encounters with many men (Kristiansen, 2003).

In 1996, Congress passed the Defense of Marriage Act (DOMA, Pub.L. 104–199), which defi ned marriage as between a man and a woman. On June 6, 2013, the U.S. Supreme Court in a 5 to 4 decision declared part of the Defense of Marriage Act unconsti- tutional which defi ned marriage solely as a legal union between a man and a woman.

On the same day the U.S. Supreme Court declined to address the constitutional- ity of California’s Proposition 8 ballot initiative banning same-sex marriage which kept intact a U.S. 9th Circuit Court of Appeals decision which declared Proposition 8 unconstitutional.

As of October 2013, 14 states plus the District of Columbia issued same-sex mar- riage licenses. Five states came by court decisions, six by state legislatures, and three by

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

92 II. THE REALITIES OF GROWING OLDER

popular votes. In addition, New Mexico had no law banning or legalizing same-sex mar- riages. As a result, marriage licenses for same-sex couples were issued in various counties (www.gaymarriage.procon.org/view.resource.php?reso).

HIV/AIDS AND OLDER PEOPLE

Older people are not usually thought of as a high-risk group to be exposed to the HIV virus. This is due in large part to the old misconceptions about the sexual activities of people in their later years. In addition, even professionals within the health care system are not immune to ageist thinking because many are hesitant to discuss sexual issues with their older patients. And many older persons are not comfortable confi ding in anyone about their sexual activities.

The reality is that of all HIV/AIDS cases, persons aged 55 and over account for 10.5% of new HIV/AIDS diagnoses, and 31.2% of deaths. There are more than a quarter of a million persons aged 55 and over who are currently living with HIV/AIDS, and the Centers for Disease Control & Prevention (CDC) estimates that by 2015 half of the Americans with HIV will be age 50 or older (Centers for Disease Control & Prevention [CDC], 2012).

HIV Risk Factors for Older Adults

Some factors associated with growing older tend to make older adults more vulnerable to the transmission of HIV. These include (a) the normal postmenopausal changes in women, (b) the declining effectiveness of the immune system, (c) the decreased use of condoms and other safe sex practices, and (d) the reduced likelihood that older adults have ever been tested for HIV.

Results from the West Central Florida Research Project, a survey of older persons in Florida who contracted HIV, found that 68% of those with the disease got it through unprotected sex (Nichols, 2004). The same study found that 62% of those with HIV had little or no knowledge of the disease or the risky sexual behaviors that can lead to its spread. The rise in divorce rates among the old, and the widespread reality of widow- hood among women and to a lesser extent among men, increases the likelihood that more older persons will have multiple sex partners during their life span. In addition, medications to improve sexual functioning, such as Viagra, extend active sexual activities of people into their later years. All of this demonstrates the need for health and disease prevention education aimed at older adults.

PRACTICES TO ENHANCE SEXUALITY IN AGING

To spice up their sex lives, Baby Boomers (and many elderly persons) have been experi- menting with sex practices and activities that in an earlier time would have seemed for- bidden or racy.

Masturbation/Mutual Masturbation

An increasing number of older people say they have masturbated at least once in the last 6 months. Almost 50% of women aged 45 to 49 report masturbating, while 20% of those aged 70 and older report doing so. A majority of all women—even those aged 70 and over—say that self-stimulation is an important part of sexual pleasure at any age. The

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.gaymarriage.procon.org/view.resource.php?reso

6. SEXUALITY AND AGING 93

rate of masturbation among men has not changed much in the last few years (Jacoby, 2005).

When one hears someone talk about having sex, being sexually active or sexually involved, being in a sexual relationship or intimate with someone, it is usually assumed these phrases refer to sexual intercourse. This has been a part of the American culture. In an article proposing a new and more realistic approach to sexuality, Dr. Sylvia Hacker (1990, p. 93), of the University of Michigan, advocates new sexual norms for society. She indicates that sexual intercourse is only one part of a wide range of sexual activities that can bring pleasure and satisfaction to people. She points out that sexual pleasure can be achieved outside of sexual intercourse. For example, men get pleasure from ejacula- tion, which can be achieved by masturbation; but the greatest pleasure is achieved when both sexual partners have orgasms, which are not achieved by many women through intercourse. This is particularly true for older, postmenopausal women who lose vaginal lubrication. Many women do not achieve orgasm through sexual intercourse because of a lack of adequate stimulation, and intercourse can be painful without supplemental lubrication.

Dr. Hacker focused on developing “great lover” techniques, which include slowing down and getting in touch with each person’s sensuality. This means achiev- ing very pleasurable orgasms by focusing on bringing pleasure to each partner through touching, caressing, massaging, hugging, fondling, and bringing to orgasm each partner by manipulation. For older persons who have been socialized in an old cultural norm of sexuality, mutual masturbation/pleasuring can be a liberating experience.

Other Forms of Sexual Stimulation

Media spokespeople have emerged to promote a sexual liberation theme for older people as well as the emerging old (Baby Boomers). Perhaps two of the most well known have been Dr. Ruth Westheimer, who makes media appearances as Dr. Ruth speaking honestly and forthrightly on a wide variety of sex-related topics, and Sue Johanson, a leading sex educator in Canada for more than 30 years.

Good sex after midlife is an important theme of Johanson’s. “Who says you shouldn’t have exciting sex after 70?” she asked (Matthews, 2004, p. 25.). Johanson points out that arousal in both sexes takes longer in the later years, and the need for orgasm diminishes greatly. But she contends that the need for a sex life is ongoing, even if the grown children disapprove or say, “Mother! At your age!” She contends that sex in nursing homes and assisted-living facilities is becoming more common.

She dispels myths and reassures people who call in to her radio or TV programs about specifi c sexual practices and even fetishes—but always from a safe sex approach. For example, in response to a woman caller who was upset by her husband wearing women’s silk panties while masturbating, Johanson assured her that this kind of role- playing is nothing to worry about. She advised her to let him enjoy it and enjoy it with him. Experimentation is encouraged if mutually agreed upon, and if it meets safe sex standards.

Johanson believes that aging Baby Boomers will permanently redefi ne post-50 sex. “Women in their 70s and 80s have begun asserting their ongoing interest in a sex life,” she said. “So why accept arbitrary age parameters? The basic rules of sex apply at every life stage”—an example of a new paradigm of aging (Matthews, 2004, p. 25).

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

94 II. THE REALITIES OF GROWING OLDER

SUGGESTED RESOURCES

American Geriatric Society’s Foundation for Health in Aging, Safe Sex for Seniors: http://www. healthinaging.org/fi les/documents/tipsheets/safe_sex_for_seniors.pdf

This document is about safe sex and made for the senior population by health care providers. It provides information on having safe sex, tips for dating and why it is important to have safe sex at an older age. It also addresses age specifi c sexual health concerns, such as ED.

Mayo Clinic, Sexual Health and Aging: Keep the Passion Alive: http://www.mayoclinic.com/health/ sexual-health/HA00035

This Internet resource discusses ways to be sexually active in a healthy way. The website provides tips on sexual health, aging, and communication in regards to sexual lifestyle. It integrates feelings and sexuality among an older population.

NIA, Sexuality in Later Life: http://www.nia.nih.gov/health/publication/sexuality-later-life The National Institute on Aging provides information on common health problems associ-

ated with aging and how they affect sexuality later in life. The Kinsey Institute: http://www.kinseyinstitute.org/ The goal of the Institute, located at Indiana University, is to have the most accurate and upto

date information on sexual health, gender, and sexual behavior. Articles, publications, and other research materials are available on the website.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.healthinaging.org/fi les/documents/tipsheets/safe_sex_for_seniors.pdf

http://www.mayoclinic.com/health/sexual-health/HA00035

http://www.nia.nih.gov/health/publication/sexuality-later-life

http://www.kinseyinstitute.org/

http://www.healthinaging.org/fi les/documents/tipsheets/safe_sex_for_seniors.pdf

http://www.mayoclinic.com/health/sexual-health/HA00035

1CHAPTER

Death, Dying, and Bereavement

The learning objectives for this chapter include understanding

Perspectives on active and passive euthanasia. ■ The stages of dying. ■ The origin of hospice and its purposes. ■ Organ donations and the process by which they can occur. ■ The various aspects of grief and bereavement. ■

PERPLEXING CASES

James has been in a nursing home for 3 years. After three major strokes, he cannot talk or take care of any of his bodily needs. In his last attempts at communication, he said he wanted to die. He has pneumonia and the staff wants to send him to an acute care hospital for intensive treatment. Should they?

Grace is being kept alive by a feeding tube. She has no lucidity. If the tube is removed, she will die. What should the family do?

Alice is 89. She is lucid but suffering from severe diabetes, which has led to the amputation of her legs and to blindness. She refuses to eat. She says that she wants to die. Should the staff “force feed” her?

Two years ago, Ralph lost his wife after 62 years of marriage. He is still in deep depression because of her death. He mostly talks about how much he misses her. He does not care to continue living and frequently says that he wishes he would die. He has not responded well to psychiatric treatment. He has a severe heart condition and refuses to take his medications. If he has a heart attack he might die, and yet he has thrown away his latest prescription. What should the family do?

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

96 II. THE REALITIES OF GROWING OLDER

David, after 46 years of marriage, is struggling with what type of funeral he should have for his wife. In his grief and lack of knowledge about funerals, he is totally dependent on the funeral director. His bill for the funeral will be $6,750. Excessive? Moderate?

Martha has been attending Widowed Persons meetings for the last 15 months. It has helped her though the grieving process. She is now beginning to have interesting conversations with some of the men at the meetings. She is 69 and is beginning to think of “dating.” Most of the men are in their 70s. Should her children be worried about the relationships that their mother might be developing?

Peter is 63 and quite rich. He has been a widower for 2 years. He is retired and in excellent health. If he wanted to, he could spend his time traveling around the world. He is dating a 46-year- old divorcee with two dependent children. Peter’s three children are worried that their father is going to spend the rest of his life supporting and being devoted to another family. They think he is being set up. Should his children be concerned?

DEATH: A NORMAL PART OF HUMAN EXISTENCE

In spite of the marvelous advances that have been made in medical technology, the increased availability of medical services, and a better standard of living for many people in the United States that has resulted in a considerable longer life expectancy in this cen- tury, death is still part of all human existence. Death is not abnormal; it comes to all liv- ing creatures. As Leming and Dickinson (2011) wrote, “Dying is a human activity that is carried out in a normative manner. Each individual learns from society the meaning of death and the proper ways to die. One hopes to die what one’s culture considers to be a good death” (p. 172).

Avoiding Talk of Death

For an older person, death is expected and becomes a normal event (Leming & Dickinson, 2011). The problem of death for older people is not so much death itself, but how and under what circumstances death will take place (Gates, 2007).

Until recently, Americans tended to be willing to discuss death in the abstract but were uncomfortable discussing their own deaths. Death in American society tends to be hidden in hospitals and nursing homes, and few Americans see their relatives die. They are told that death has occurred. Most people say they want to die at home, but most do not die there.

As so many people in American society are not comfortable discussing death other than in the abstract, many euphemisms are used to refer to death or dying, such as the departed, passed on, expired, passed away, succumbed, croaked, cashed in, checked out, and six feet under. As a result, many people are ill at ease talking to someone about the death of a close relative or about a patient’s imminent demise.

In our death-denying culture, it is an unfortunate fact that even professionals, who reg- ularly work with those who are aging, such as physicians, nurses, health professionals, and clergy, often lack education regarding issues related to death, dying, and bereavement. This point is further explored in the Practical Application at the end of Part II of this textbook.

History of Funerals

At one time in American history, most people died at home. Now approximately 70% die in an institutional setting. In keeping with banishing death from the homes of America to hospitals or nursing facilities, funerals (including paying respects and sharing grief Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

7. DEATH, DYING, AND BEREAVEMENT 97

with relatives, friends, and neighbors) have been moved from the family parlor to funeral homes (Leming & Dickinson, 2011). Following the Civil War, middle-class Americans began to replace the formal parlors in their homes with what were called “living rooms.” Corpses were no longer laid out in family living rooms. All of this has made death more distant to the family setting and more removed from the normal life cycle (Auger, 2007).

FEAR OF DEATH

Similar to people of all ages, older people have some fears and concerns as they become closer to death. Research has indicated that older persons think about death more than younger people do, but the elderly seem to be less fearful and have less anxiety about it (Leming & Dickinson, 2011). Research over the years is not clear as to why older people seem to fear death less than younger people do. Kalish (1987) pointed out that there may be at least three reasons. The old may believe that they have lived their lives to the fullest, and as a result, they have a sense of completion and realize that death is the next natural part of the life cycle. Some are in a painful, prolonged, hopeless illness where they see death as a release from pain and suffering. Others have lost so many friends and relatives that they increasingly feel isolated from others. They have seen their spouses and close friends die and have “less to live for.” One of the results of living into the oldest-old years is that one loses most of one’s friends to death at a time when physical disabilities can make it hard to make new friends.

Fear of the Dying Process

Older people do have some anxieties as to how and under what circumstances they will die. Many years ago, Balfour Mount (1976) found that there are several concerns people have about the dying process. Many people fear that they may die alone, have consider- able pain, become a burden to their loved ones, and become a fi nancial burden for their family. In addition, some have indicated a fear of death itself, of the unknown, of what happens after death.

Neimeyer and Van Brunt (1995) discussed the fears of dying that people may have as a result of their religious beliefs about a life after death: concern about punishment for what they have done; fear of being abandoned; fear of pain and indignity; and fear of being nonexistent. Women seem to have more fear about death than men, or they may be more open in expressing their fears. The authors also indicated that research does not show that education about death reduces the fear of death. In fact, there is some evidence that death education may increase the fear of death.

SUSTAINING LIFE: A THORNY ISSUE

Over 30 years ago, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1981) stated that there is little debate over the fact that the human body can be kept alive almost indefi nitely with intravenous fl uids, tube feedings, and various advanced medical technologies. This commission also stated that humans can be kept physically alive whether or not there is any brain function.

Refusing Treatment

Once they go to a hospital, people can become “trapped” in a situation of complex tech- nology in which their bodies continue to survive even if there is no lucidity and no hope of recovery. At that point, the hospital staff may prefer to discontinue treatment, but they Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

98 II. THE REALITIES OF GROWING OLDER

are caught in a maze of legal requirements and therefore continue the treatment because they fear litigation. A federal law, enacted on December 1, 1991, called the Patient Self- Determination Act requires hospices, nursing homes, hospitals, and home health care agencies to provide patients with information about their right to determine whether they want “extraordinary” means used to keep them alive if they become comatose or hopelessly ill. The law requires that each person entering an institution be given informa- tion about his or her right to refuse treatment.

By 1986, the American Medical Association declared that whenever the question to sustain life becomes an issue, the patient’s choice should prevail. In that spirit, Barbara Bush, wife of the former fi rst President Bush, acknowledged that she signed a living will, commenting “I had a dog I loved put down because I didn’t want the dog to suffer; I cer- tainly hope that someone would do the same thing for me” (cited in Burnell, 1993, p. 8). Burnell (1993) stated the dilemma as follows:

Part of the confusion over the concept of dying lies in the fact that many people are not aware of the new ways of defi ning death. Formerly, a person who stopped breathing and had no heartbeat was considered dead. Now, brain function is also considered in the defi nition of death. In recent years, we have come to recognize that there is more to a person than just a body. The brain plays a major role in providing each of us with a personality, a set of unique behaviors and traits. These, in essence, are what distinguish us from others and give us what we call our identity. (p. 16)

A patient’s choice may be determined by a legally chosen advocate through something called a durable power of attorney for medical decisions. Although the American Medical Association has been strongly opposed to a doctor taking an active role in helping people die, not all doctors agree. Surveys of U.S. physicians’ attitudes reveal that about one third would participate in physician-assisted suicide if it were legalized (Dickinson, Clark, Winslow, & Marples, 2005). In Dying with Dignity, Patrick Sheehy (1981) wrote:

We can also predict what the quality of the remaining time will be for the patient. If death is imminent, and if there are only the throes of physical pain and struggle left, I believe that a doctor should be allowed to give you a drug that will painlessly release you to death. As society matures, I foresee a time when this will be possible. (p. 236)

In some countries, that time has arrived. Current evidence seems to indicate that the desire of most people to die with dignity is becoming a national dialogue involving a defi nition of terms such as death with dignity, uncontrollable pain, extraordinary methods to keep people alive, and the meaning of alternative methods of treatment. In addition, there will be continuing theological and philosophical disputes about the meaning of life as well as arguments about the medical costs of sustaining life in comatose patients who are in a vegetative state.

LIVING WILLS

Through a living will, Americans can make their wishes known regarding whether heroic methods should be used to keep them alive. In a living will, prior to an emergency situ- ation, people can indicate to medical staff and their family, in a written document, their wishes about the type of medical care they wish to have, or not to have, under certain conditions. It essentially spells out a refusal of certain types of treatments, but it usually cannot be used for stopping treatment that has begun. As a result, a person with a living C

op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

7. DEATH, DYING, AND BEREAVEMENT 99

will could be taken from a nursing home in a medical emergency and given treatment that seems reasonable. However, during the treatment the person may suffer a severe stroke. If the staff reacts quickly and gives life-sustaining care, and the person then drifts into permanent subconsciousness, at that point the staff will not usually withdraw treat- ment that has begun. The reason for this is that they probably fear a lawsuit because if they remove the treatment, they may be charged with killing the person. In addition, fam- ily members, because of feelings of guilt, love, or other reasons, may not permit the staff to remove the artifi cial life-sustaining equipment. It is not uncommon for a living will to contain vague terms such as no extraordinary means, or no heroic methods, which the family will be asked to defi ne, and they may disagree among themselves as to their meaning.

Durable Power of Attorney

For many people the living will is a desirable statement, but in itself it is often inadequate. As a result, many experts also recommend a durable power of attorney for medical care. The durable power of attorney for medical care designates an individual to make treatment decisions for a person who no longer has the mental capacity to do so. The living will, then, tells the person designated by the durable power of attorney for medical care the wishes of the person who is no longer mentally competent to make those decisions.

EUTHANASIA

Euthanasia is a word so fi lled with emotional reactions that it probably should no longer be used. In its original derivation, it means will (eu) and death (thanatos). The emphasis is on a “good,” painless death. The term became despised by many because of its use by the Nazis under Hitler’s orders to exterminate certain categories of people such as the retarded, the mentally ill, Jews, political dissidents, homosexuals, gypsies, and oth- ers. The word euthanasia is inappropriately used in that context, because these persons were murdered. They did not choose “good” deaths. They were eliminated because of the criminal acts of Adolf Hitler.

In some ancient societies, euthanasia was socially acceptable. In Athens of ancient Greece, for example, judges had a supply of poison available for those who wished to die. The evidence indicates that permission to use the poison was not diffi cult to obtain (Burnell, 1993).

The term active euthanasia is commonly taken to mean purposely and deliberately tak- ing action to end an individual’s life. The term passive euthanasia refers to deliberately not taking any action to prolong the life of someone who is dying or existing in a vegetative state.

Euthanasia in Holland

There is much misunderstanding about euthanasia in Holland. It is a topic that has been debated much longer there than in the United States. The Dutch do not require that termi- nal illness be the only permissible grounds for assisted death. They consider death with dignity to be an important consideration. It must also be understood that the doctor– patient relationship in the Netherlands is based on more trust and personal interaction than is the case in the United States. The typical Dutch patient in assisted death is usually a person in his or her early 60s who has an advanced case of cancer. About 85% are cancer patients in their last few weeks of life. The remaining patients typically have AIDS, mul- tiple sclerosis, or other neurological diseases that cause paralysis.Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

100 II. THE REALITIES OF GROWING OLDER

Research on Euthanasia

Current research in the Netherlands has found that physicians grant 44% of adults requesting euthanasia. They turn down 12% of the requests. In 13% of cases where the request has been granted, the patients died before the euthanasia occurred. In another 13% of cases, the patients changed their minds about euthanasia. In the rest of the cases, the decision was not made at the time of the study. This research provides a beginning indication of how physicians might react to such requests. Much more research will need to be done before the above types of questions will have some empirical answers. Outside of the philosophical and theological questions involved in euthanasia, much more study needs to be done as to what type of persons will request euthanasia and how the medical community will respond. Of the 136,000 annual deaths in the Netherlands from 1985 to 2005, 1.7% were by voluntary euthanasia (USA TODAY, 2007).

U.S. Legal Positions on Euthanasia

In the United States, some states allow terminally ill people to engage in assisted suicide. The Oregon Department of Human Services’ Annual Report of 2010, which details the Oregon Death with Dignity Act, indicated that 65 people died in 2010 under the terms of the Act. This report showed that the dire predictions by the opponents of the Act—that it would lead to coercion, excessive use, or acting because of depression—did not occur. Indeed, there was not one report of abuse of the Act. The report also indicated that for the 11th year in a row, Oregon’s Death with Dignity Act had proven to be effective (USA TODAY, July 20, 2009).

The United States Supreme Court has upheld Oregon’s law, and Judge Sonia Sotomayor, in her Supreme Court Confi rmation Hearings, stated that she would follow precedent (USA TODAY, July 20, 2009). The state of Washington in March 2009 became the second state to have a voter-approved assisted suicide law. This law requires a 15-day waiting period between the fi rst oral and fi rst written request for a lethal medication, and an additional 48 hours before a prescription can be written. This delay is intended to prevent someone from acting hastily and without adequate thought. A majority of Americans (56%) in a Gallup Poll have indicated support for doctors to be allowed to assist terminally ill persons to die (USA TODAY, July 20, 2009).

THE PROCESS OF DYING

Having looked at some of the current major issues and debates surrounding death and dying, it is important to examine the process of dying as well as some of the approaches that have been developed to begin to understand and cope with this process.

The Stages of Dying: Kubler-Ross

Kubler-Ross (1969, 1975, 1981) found that people tend to go through fi ve stages in the dying process. When they are fi rst diagnosed with a terminal condition, they refuse to accept the situation. They deny the reality of their situation and live in a condition of unreality in which they believe that the situation will change, that there is a misdiagnosis, and that new developments will help them. In the second stage, anger and resentment, they curse their fate, feel that the situation is unfair, and may project their anger and resent- ment onto medical staff or family members. In the third stage, bargaining, they may plead with God, promise that they will change their behavior, devote themselves to religious or worthwhile causes, and promise that they will no longer engage in certain types of C

op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

7. DEATH, DYING, AND BEREAVEMENT 101

questionable behaviors if they get a “second” chance at life. In the fourth stage, depres- sion, they admit that their condition is terminal, that death is imminent, and that they are not going to be cured. They may then go into a stage of grief and isolation. Relatives and friends may fi nd it diffi cult to communicate with them, and they may reject visits. In the fi nal stage, acceptance, they accept their death. This is not a stage reached by all dying per- sons. It is a stage in which some feel that their life is going to end soon and that they have done all that they could regarding the situation. It is a stage achieved by those who have been able to relate their feelings to others and who have a sense of completion regarding their life’s journey.

It is important to note that not everyone goes through all of these stages. Nor do the persons who go through all of these stages go through them in the same order (Bonanno, 2009; Bryant, 2003). Medical personnel or family members should not try to force dying persons into any one of these specifi c stages.

Educating Medical Staff

In recent years, there have been some attempts to educate medical personnel about death and dying, especially about the needs of the dying patient. With a greater empha- sis on the practice of holistic medicine by many of the nation’s medical schools, a greater awareness of the needs of the dying patient and his or her family and signifi cant other should be expected. Without this awareness and approach, a sort of “social death” occurs when the attending medical staff no longer see the dying patient as a unique person with specifi c psychological needs, relationships, and spiritual dimensions. Given the current interest in death and dying, it is likely that the treatment of terminally ill patients will improve.

THE HOSPICE MOVEMENT: ORGINS AND GOALS

An international trend in the care of the dying is the hospice movement. Dr. Cicely Saunders played a key role in the development of the modern hospice movement when she started St. Christopher’s Hospice in 1967 in London, England. The goal at St. Christopher’s Hospice was to make an assessment of the spiritual, physical, social, and psychological needs of the dying person and of his or her support network. It was based on a belief that dying can occur best at home or in a specialized institution where there is a concerted attempt to reduce pain and to give the person supportive care that allows him or her to maximize relationships with others during their dying process. It is a program for persons who cannot be cured of their physical illnesses, so the emphasis is not on curing the condition, but on enabling the person to die “in comfort” with a caring, sup- portive staff and with friends and relatives. To defi ne this approach further, Buckingham (1983) wrote:

Hospice is a medically directed multidisciplinary program providing skilled care of an appropriate nature for terminally ill patients and their families to allow the patient to live as fully as possible until the time of death. Hospice helps relieve symptoms of distress (physical, psychological, spiritual, social, economic) that may occur during the course of the disease, dying, and bereavement. (p. 3)

It is important to note that the goal in the hospice movement is to maximize the qual- ity of life for the dying patient and to make the best use of the time remaining with relatives, friends, and acquaintances. In addition, there is a focus on the comfort of the patient.C op yr ig ht @ 2 01 4. S pr in ge r Pu bl is hi ng C om pa ny .

102 II. THE REALITIES OF GROWING OLDER

Key Aspects: Patient Care

Even though there are different types of hospice programs, they are all unifi ed by their general philosophy of patient care (Leming & Dickinson, 2011). Hospice care is focused on patients with life-threatening illnesses. About 95% of the hospice patients in the United States suffer from cancer.

The Spread of Hospice in the United States

The fi rst modern hospice program in the United States grew out of Dr. Cicely Saunders’ lecture in 1963 at Yale University in New Haven, Connecticut, and her subsequent con- tacts with personnel from Yale nursing and medical schools. Representatives of various disciplines became involved in the development of Hospice Incorporated in 1971, which was later changed to the Connecticut Hospice (Leming & Dickinson, 2011).

VITAL ORGAN DONATION PROGRAM

The death of one human being can mean the gift of some key bodily functions or even life itself to another—in some cases several others, if multiple vital organs are utilized.

Federal law now requires hospitals to inform patients and family members about organ donations. There are many misconceptions about organ donations. To correct these misconceptions, Burnell (1993) pointed out:

Donating organs will not interfere with receiving medical treatment in a hospi- ■ tal. Doctors are not more interested in obtaining organs than in providing their patients with proper treatment. Organ donation is considered only after all attempts to save a life have been made. ■ Organ donation will not take place until the heart has stopped beating or brain ■ death has been established. For viable organs, such as the heart, the lungs, the liver, the pancreas, and the ■ kidneys, to be harvested, brain-dead individuals must be maintained on a res- pirator. However, the donation of eyes, bone, skin, and other tissues does not require maintenance on a respirator. These tissues can be obtained from 6 to 24 hours after breathing and the heartbeat have stopped. The body will not be disfi gured by organ donation. After the removal of the ■ donated organs, the surgical team will leave the body intact for proper funeral or burial arrangements. The family does not receive any compensation or fee for the donation. It is illegal ■ to buy or sell organs or tissues. There is no charge or fee connected with the removal of organs or tissues. ■ All major religions support the concept of organ and tissue donation as well as ■ the concept of brain death. Organ donation does not interfere with funeral arrangements. Funeral directors ■ can direct embalmers to prepare the body appropriately. The most common organ and tissue transplants are skin, lungs, hearts, livers, ■ kidneys, corneas, certain bones, pancreases, and middle ears. Time is of the essence in most organ transplants, except for skin and corneas, so ■ the removal of most organs is likely to occur in an acute care hospital. Even if a person has indicated his or her wish to donate organs, the medical ■ transplant team may not automatically accept the donation. Many variables must be considered, such as the health of the donor.Co

py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

7. DEATH, DYING, AND BEREAVEMENT 103

Generally speaking, organs are more suitable if they come from people under 70 ■ years of age. Also, the organs of cancer patients (except in some cases of brain cancer) or of patients with infections or other serious diseases are not suitable for donation. Transportation and other incurred costs are usually covered by the organizations ■ procuring the organs for transplant. There are many organizations that coordi- nate organ donations. Whether or not a person decides to donate his or her organs, there is a federal ■ law that requires hospitals to inform the families of deceased patients about the option of organ donations. Organ donation does not interfere with a living will, which refers to one’s wishes ■ while one is still alive. (pp. 299–301)

FUNERALS

Anthropologists have found that all the cultures they have studied have some form of funeralization process—a rite or ritual recognizing death and a fi nal disposition of the dead body (Leming & Dickinson, 2011). All cultures have ritualistic aspects to mourning death and some type of public ritual that families and friends go through. Aspects of these rituals vary from one culture to another. In the United States, funerals vary enormously according to social class, race, ethnicity, religious affi liation, and geographic location, but it is the funeral that becomes the focus of ritual.

Social Roles of Funerals

The funeral is a social event that brings the chief mourners and community members to the reality of death. In addition, it allows people to express their sympathy and give sup- port to the relatives and friends of the deceased. It develops a context in which people are expected to come and greet the family. It is an event that one attends even though one does not receive an invitation. Even though a person may fi nd it diffi cult to express his or her feelings of sympathy and support to the relatives, just being there makes a statement of support (Leming & Dickinson, 2011).

Another function of the funeral is to provide a theological or philosophical mean- ing for one’s life. For a religiously oriented person, a cleric usually speaks about the pur- pose and meaning of life, along with a eulogy about the deceased (Leming & Dickinson, 2011).

The funeral enables members of the community to express their regards to the liv- ing by sending sympathy cards or fl owers or by giving to charities named by the relatives of the deceased.

Making Decisions About Funerals

Funeral directors (undertakers, morticians) at times have been accused of taking advan- tage of people who are in a state of shock and depression at the death of a family member or close friend. The most scathing attack on the funeral industry was fi rst made by Jessica Mitford in 1963. She accused funeral directors of infl ating prices, misleading grieving family members, overselling unneeded services, and generally being dishonest in their dealings. She contended that they could do this because many persons are in unfamiliar surroundings at a mortuary and are too trusting of funeral directors. Since the publi- cation of her book and the intense publicity it received, national legislation has been Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

104 II. THE REALITIES OF GROWING OLDER

implemented to regulate the funeral industry more closely. Even so, an updated edition of Mitford’s book (2000) entitled, The American Way of Death Revisited, sheds light on new trends in what she terms the death-care industry, including the rising costs of cremation, which used to be a less expensive alternative to burial, and new organizations dedicated to keeping costs in tow. The industry contends that Mitford exaggerated the number of dishonest funeral directors and that it now is better at regulating itself. Others argue that self-regulation of an industry is always suspect because of vested and confl icting inter- ests, cronyism, and a reluctance of members of any industry to publicize its problems.

More and more Americans are choosing cremation over traditional funerals. Forty- one percent of Americans now choose cremation compared to 21% in 1995. This change, in part, is the result of a signifi cant difference in price as a basic cremation costs about $1500, while a traditional funeral costs about $10,000 (The Week, 2011, p. 10).

BEREAVEMENT AND GRIEF

Diana Harris (2007) states that “there are three distinct phases in the bereavement process. In the fi rst phase, there is a period of shock that lasts for several days. This is followed by a second phase of intense grief, which can even have physiological effects including loss of appetite, insomnia, loss of weight, etc. In the third phase one begins to recover and resume social interaction” (p. 125).

Some persons have anticipatory bereavement in which they grieve as they watch a spouse or a parent lose any sense of self-awareness because of Alzheimer’s disease, or some other disease causing a lengthy dying process. For some, death then produces a feeling of relief as there is fi nally closure for which the grieving has already taken place.

Most grieving persons eventually begin to adjust to the reality of the death and begin to work their way back into their social world without their deceased spouse, child, sibling, or friend. At that point, the person begins to get back into their normal routine, although grieving for some brings about a psychological condition that needs profes- sional counseling (Roos, 2002). There are processes that grieving people go through, but the length and stages of grieving, and the intensity of the grieving process, vary tremen- dously depending on the personality, the relationship with the deceased, and the way the death occurred.

WIDOWHOOD

There are millions of widowed persons in the United States, with widows (women) out- numbering widowers (men) by a ratio of fi ve to one. Most older women are widowed, while most older men are married, the result of the reality that women live longer than men, and that men tend to marry younger women.

Helen Lopata’s (1979) classic study on widowhood, Widowhood in an American City, found that there are widely different reactions by widowed persons. Some become iso- lated, while others seek out new friendships and experiences; some may develop new talents or fi nd or rediscover abilities that were repressed; and some may become very passive and struggle over a long adjustment time, while others are able to adjust rather quickly.

The AARP founded the Widowed Persons Service (WPS) back in 1973 to meet the emotional and practical needs of newly widowed persons of both genders. There are thousands of WPS volunteers located in hundreds of sites across the United States, serv- ing tens of thousands of newly widowed persons each year by telephone calls, visits, and WPS-support group meetings.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

7. DEATH, DYING, AND BEREAVEMENT 105

Mourning for a deceased spouse usually takes more that just a month or two. For some people the mourning process is never totally over, while for others, mourning may involve 2 or 3 years of grieving (Gibala, 1993). Becoming a widow or widower usually results in severe stress, typically more stress than is involved in losing a job or having a major illness.

The WPS outreach volunteers function as support persons, as “bridges over trou- bled waters,” and for some, as new friends:

In addition to one-to-one outreach, WPS sponsors group meetings. Because warmth and caring are primary needs of the widowed, WPS meetings fi rst offer hugs, more hugs that you can count. . . . The participants share their stories, discuss their wor- ries, offer coping skills, and receive accolades for meeting personal challenges. A guest speaker may talk about a range of topics such as crime prevention, cooking for one, or adjusting to widowed life. (Gibala, 1993, p. 7)

SUGGESTED RESOURCES

Coping with Grief and Loss: http://www.helpguide.org/mental/grief_loss.htm This website is dedicated to health challenges in general and has a page solely for grief and

loss understanding. The site offers information about the stages and symptoms of grief, with suggestions for coping with grief, when to seek counseling, and support group options.

End-of-Life Issues: http://www.usa.gov/Topics/Seniors/EndofLife.shtml This federal government website offers information on grieving, funerals, hospice care, care-

taking, and living wills. There is a link to a hospice care locator, which has a search tool for palliative care, hospice care, grief counseling, and in home services in your area.

National Hospice & Palliative Care Organization: http://www.nhpco.org This organization has a website for services that offer everything related to palliative care,

hospice care, and grief. You can fi nd links to other sites and organizations that offer services such as grief counseling, help witih hospice, end of life services, and after life services.

Oregon Death with Dignity Act, available through http://public.health.oregon.gov This organization has a website for services that offer everything related to palliative care,

hospice care, and grief. You can fi nd links to other sites and organizations that offer services such as grief counseling, help with hospice, end of life services, and after life services.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

http://www.helpguide.org/mental/grief_loss.htm

http://www.usa.gov/Topics/Seniors/EndofLife.shtml

http://www.nhpco.org

http://public.health.oregon.gov

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

Practical Application I

107

The Realities of Growing Older

Michael A. Faber

INTRODUCTION

The fi ve chapters in this section provide a detailed description of the aging process, aging- related physical changes, health and wellness, mental health and abilities, and sexuality and aging, as well as death and dying. The focus of this Practical Application will be on healthy aging, motivation for wellness, adaptation to aging-related loss, independence versus interdependence, mental health stereotypes and stigma, as well as refl ection on life and death.

Healthy Aging

Healthy aging is a topic that should concern us all, since we are all aging. By now, in our information-laden age, most everyone is aware of the right things to do to take care of themselves. It’s not rocket science after all. Healthy aging involves eating right, exercise, no use of tobacco, moderation of alcohol, avoiding stress, and adequate sleep and relax- ation. Knowing this, why is it that most of us don’t do the right things?

Lifestyle choices, long-established habits, changed life patterns (where in the past people either didn’t know better or didn’t make time for physical activity), changes to our food sources, and a lack of knowledge regarding what constitutes proper nutrition have all contributed to a large number of individuals aging in unhealthy ways. Therefore, let’s examine the factors that help to motivate older individuals to do the right things in regard to their health and wellness.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

108 II. THE REALITIES OF GROWING OLDER

Motivation for Wellness

Everyone knows the right things to do, so why don’t they do them? For those choosing to enter the fi eld of gerontology, this is an important question and issue to address. One way that we can help to improve, and perhaps even extend, the lives of those we serve is by learning to understand personal “motivation” and help identify ways to motivate and encourage those we serve to make healthier lifestyle choices.

According to the Encarta Dictionary: English (North American edition), motivation is defi ned as “giving of reason to act” or “the act of giving somebody a reason or incen- tive to do something.” Using this defi nition, an informal survey was administered to a group of older individuals at a local senior center by this author. Those identifying them- selves as exercising regularly were asked what motivated them to do so—their responses included the following:

An urgency brought about by specifi c chronic diseases/conditions (heart, fi bro- ■ myalgia, arthritis, stroke, high cholesterol, etc.); Fear based on family history (life-limiting genetic conditions); ■ A desire to maintain balance and mobility; ■ Wanting to control their weight; and ■ Probably even more telling, those who identifi ed themselves as ■ not exercising regularly, when asked why not, said it was due to laziness, discouragement, or conditions such as shortness of breath that made it diffi cult to exercise.

Understanding the motivations of an older person is the starting point for posi- tive intervention through education, encouragement, and the provision of appropriate supports.

Aging, Loss, and Adaptation

Far too often, the aging process is described in terms of loss and decline. In reality, the majority of older persons live happy, healthy, active, and productive lives. Yet, for many in the oldest-old age category (85+) aging-related losses are commonplace. Therefore, it is important to understand these losses and how to help older adults adapt to these aging- related challenges.

In order to accomplish this it is important to realize:

Most older persons are fl exible and used to adapting to change; ■ Educating older persons and their caregivers about aging-related losses and how ■ to cope with losses increases the probability of adapting to life’s changes; and Relating to the older persons as adults and not children involves including them ■ in any care planning or problem-solving discussions.

Older adults often experience a number of aging-related changes and losses includ- ing but not limited to decreased physical abilities (i.e., changes in mobility, fl exibility, vision, hearing, taste and smell, and sensitivity to hot and cold); loss of the “work” role through retirement; reduced income; changed social and familial roles; and the loss of family and friends due to death. Aging successfully involves adapting to such changes and losses. Listed below are a number of helpful tips on how to help older persons adapt to some of the more common aging-related changes.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

II. PRACTICAL APPLICATION: THE REALITIES OF GROWING OLDER 109

Mobility

Encourage regular exercise to maintain fl exibility and strength—core strength is ■ especially important to prevent falls. Make the home barrier free—eliminate potential causes of falls including clutter, ■ slippery fl oors, throw rugs, extension cords, etc. Promote the use of assistive devices when needed (canes, walkers, etc.). ■

Vision

Install proper lighting in the home—lighting should be bright, without glare or ■ shadows, and should be brighter in areas used for reading. Use fl orescent tape or paint to delineate edges of stairs, platforms, and counter ■ tops. Avoid walking in the dark at night—use night lights, fl ashlight, or other lighting ■ options, and eliminate possible barriers in the home. Use specially marked larger knobs and dials on appliances. ■

Hearing

Speak clearly, distinctly, and do not shout—shouting increases your pitch, and ■ the higher pitches are most often lost fi rst due to the aging process. Eliminate background noises. ■ Face the person and look them directly in the eyes when speaking—this will help ■ older adults who supplement what they hear by reading lips. Encourage the use of assistive devices, such as hearing aids and telephone ■ amplifi ers.

Touch

Touch is an important form of communication—older persons, especially those ■ who are isolated and alone, often crave appropriate forms of human contact/ touch. Pay attention to extremes in temperature—older persons’ internal thermostats ■ do not work as effi ciently as do those of younger people, and therefore they are at higher risk for hypothermia.

Taste and Smell

Encourage the use of a variety of herbs and spices to season foods—many older ■ adults must avoid the use of salt and are not very knowledgeable of the proper use of alternative seasonings. Make sure that foods served to older persons are colorful and attractive—the ■ more appealing the food, the more likely it is to be consumed. Use safety devices, such as smoke detectors and timers, especially in areas of ■ meal preparation, to prevent possible fi res and the burning of food. Date and store all leftovers in the refrigerator—never leave meat or other pre- ■ pared food items on the counter to defrost or cool.

Co py ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.

110 II. THE REALITIES OF GROWING OLDER

Independence Versus Interdependence

Independence is highly valued in American culture. It is a learned behavior from a very young age, as demonstrated in a 2-year-old loudly and proudly declaring, “I do it myself!” Yet, in reality, people need people, and most of us are not truly independent as much as “interdependent” on one another. Popple and Leighninger, in their work Social Work, Social Welfare, and American Society (7th edition, Allyn & Bacon, 2008), defi ne interdepen- dence as “dependence on each other or one another; mutual dependence,” and dependence as “a state of being in which one is not able to participate as a social being in rewarding ways and, thus, is a proper opposite of interdependent.”

Unfortunately, far too often older persons only see things in terms of independence versus dependence, rather than thinking about the value of interdependence. Part of the role of a professional working with older persons is to help them to recognize their inter- dependence. If successful in doing so, the older adult often has a greater openness to accepting needed support and assistance. Another important rule of thumb is to never do for an older person what she or he is able to do herself or himself, for this may lead to unnecessary dependence and a sense of diminished value or worthlessness on the part of the older person.

Mental Health Stereotypes and Stigma

Many of those in the oldest-old generation grew up at a time when mental health issues were not socially acceptable. To suffer openly from even common mental health issues, such as depression and anxiety, an individual risked social isolation and stigma. Therefore, most individuals learned to keep these types of issues to themselves and/or quietly within their family, without seeking competent professional assistance. In other words, they would suffer needlessly in silence. Unfortunately, this means that many older adults today continue to suffer in silence. These same individuals fail to share their concerns related to depression, anxiety, memory loss, or other mental health issues with loved ones, a physician, or a mental health professional. What does this mean to those of us who choose to work with older persons? It is this author’s opinion that it is the respon- sibility of those of us working in the fi eld of gerontology to recognize the mental health issues of those we serve and educate and encourage them to seek appropriate treatment. In other words, we need to work to dispel the stereotypes and stigmas surrounding men- tal health conditions and their treatment.

Death, Life, and Possible Lessons

This section includes information on death and dying. In many ways, American culture is denying death. Not all professionals in medicine, health care, social service, or pas- toral care have received extensive education or training in dealing with death, dying, and bereavement. Yet, if one is to work with older persons, a thorough understanding of death, dying, and bereavement is important. Therefore, it is recommended by this author that anyone choosing to work with this population include the study of thanatol- ogy (death, dying, and bereavement) as part of their education.

In studying death, dying, and bereavement, one not only becomes more under- standing and empathetic toward those in our care, but one can also learn many powerful lessons about life, such as the value of living life to the fullest, embracing each new day, and recognizing one’s true priorities.

PCopy ri gh t @ 20 14 . Sp ri ng er P ub li sh in g Co mp an y.