Appreciating the role and scope of psychosocial aspects of aging improves clinicians’ ability to address and treat factors that have important bearing on the overall well-being of older persons. Health events have broad ramifications. When they are viewed within a framework that includes both the stressors and the means to ameliorate the impact of stress, other factors besides the treatment of the disease itself can be seen to need clinical attention.
Stressors are any demands that call forth a physiologic, behavioral, or emotional response; often, such demands are perceived as threats. Unchecked stressors can lead to negative outcomes directly related to the situation as well as to more indirect negative outcomes across the whole spectrum of physical and mental health, economic welfare, and family life. Given the range of demands posed by the stressors, it is evident that they can greatly affect a person’s physical and mental health, including every aspect of his or her well-being. The person’s ability to function in the world may be reduced; the enthusiasm the person brings to and the pleasure he or she takes from social interaction may also be reduced. The use the person makes of financial, health, and social service resources may also be strongly affected.
Figure 3.1 offers a framework for considering the complex interaction of physical and psychosocial factors shaping the outcomes of stressors confronting older persons; the figure also structures the material presented in this chapter. The chapter briefly discusses common psychosocial threats faced by older persons, but it is principally focused on immutable and mutable factors that bear on the direct and indirect outcomes of stress situations, all with an eye to offering the clinician important tools for treatment as well as targets for therapeutic intervention. The chapter highlights findings from social science research that indicate ways in which unchangeable facts about a person’s life (eg, gender) contribute to the outcome of stress situations—and to a person’s ability to respond to them. In particular, the chapter discusses mediators and moderators, factors that can serve to filter, though not entirely protect against, the impact of stress through different mechanisms. Mediators involve the older person’s perceptions of and responses to the stress situation. Moderators—which may be constituents of an older person’s environment or behaviors in which the person engages—can be thought of as acting on the stressor itself to lessen its intensity or buffer its effect; they also affect a person’s ability to respond to the stressor. Assisting older persons to see and work toward health outcomes that impact the quality of their life is an appropriate and effective clinical strategy for helping them to confront declines in physical health and the issues of mortality.
The older person faces a great number and variety of stressors that are produced by a broad range of events and conditions. The stressors may be chronic, or they may have sudden, dramatic onset. They may be based in diseases or they may be of a more social nature. A chronic stressor may be health related (eg, the pain and mobility limitation of arthritis) or it may be psychologic (eg, the prolonged worry over a chronically ill spouse). An acute stressor might also be physical or psychologic (eg, learning of a newly diagnosed medical condition or experiencing the unexpected death of a close friend). Other stress demands include changes in social identity due to role loss in retirement or the function-driven need to move to a more supportive living arrangement. Losses in physical capacity and reserve may place demands on the person, not only because he or she perceives them as threats or increased physical demands, but also because of their accompanying psychologic component, the perception that he or she may have diminished capacity to respond to other demands. Always in the background for older persons are the various risk factors for incident or recurrent morbidity and mortality.
Some risk factors—particularly those involving behaviors over which the person (with some encouragement, teaching, and counseling) might exert control—may be modifiable. Other risk factors, such as gender and race, are not modifiable and produce accumulated assaults that may amplify other stressors. The increasing incidence of diseases with age means that the number and frequency of stressors are likely to increase as a person ages.
Caregiving is nearly endemic; more than 44 million Americans care for family members of all ages. Gender is an important factor; more than 70% of all caregivers are women. Many older persons are caregivers for a family member. Chronic diseases affect a large proportion of elderly persons, and much of the care they receive is provided by family members, especially spouses. The burden of caregiving for dementing disorders like Alzheimer’s disease is typical. Dementia caregivers spend many hours each day in caregiving activities, and they do so for many years (20% are caregivers for more than 5 years). Such caregiving exacts a heavy toll. Caregivers are at twice the risk as their noncaregiving peers for adverse physical and mental health outcomes and more than twice as likely to be taking psychotropic medications. Social isolation, family disharmony, and economic hardships are common sequelae of caregiving.
Caregivers need training, information, and support, and they should be regularly observed for signs of the known effects of caregiving. Attention to family dynamics may also be useful in identifying issues contributing to stressors that are modifiable. A number of intervention programs (eg, those providing education, counseling, and cognitive-behavioral therapy) have proven effective in ameliorating the stress associated with caregiving. Disease-specific support activities offer only modest relief but may be the conduit for more focused help.
Being widowed, especially for women, is a common occurrence in old age; so, too, are deaths in one’s extended family and larger social network. More than 1 million spouses will be widowed in the United States in 2003; by 2030, more than 1.5 million spouses will be widowed annually. In 2000, 8.3% of those between 65 and 74 years of age were widowed; 22.7% of those older than 75 were widowed. Other losses, such as sensory and functional losses imposed by the onset of chronic or acute illnesses, also produce grief. Such losses are generally understood to be among the major negative life events, and they place a substantial demand on a person. For most, the intense experience of grief lasts 6 to 12 months, generally a time of withdrawal and depression. After about a year, a more accepting period ensues, during which a re-emergence into a social milieu occurs or a less affecting form of more permanent memorialization of the lost person is established. Acknowledgment and monitoring of the grieving process and active treatment for the depression associated with loss can help in avoiding prolongation of this process. (See also Depression and Other Mood Disorders.)
People typically encounter a large number of role shifts in aging. They leave work and social roles that may have provided economic rewards as well as status. For example, the Social Security administration made 1.8 million new awards in 2001, a year in which 2 million Americans turned 65. The average age of retirement has been in steady decline, dropping to slightly under 62 years of age in 1995–2000 (down more than 5 years since 1950–1955). Within relationships, roles may change, and wage-earning spouses, after retirement, may find themselves in significantly greater contact with each other. Grandparenthood and great-grandparenthood provide both new demands and opportunities. Functional losses may place older persons in help-seeking rather than help-providing roles, or, as noted above, another’s losses may place one in a caregiving role. These role changes can be stressful and can negatively affect mental or physical health. Retirement planning can help make these positive experiences. The clinician’s assessment of an older person’s role loss and acquisition may suggest the need for interventions.
Three factors are consistently associated in the United States with a broad range of negative psychosocial and physical outcomes: being nonwhite, being a woman, and being poor or poorly educated (usually a surrogate for being poor). They should serve as warnings for clinicians, as the presence of one or more of these factors may add to the person’s stress load. They may also affect the kinds of coping mechanisms the person has available. Lack of disposable income, for example, may exclude the use of some formal services or involvement in community activities that come with a fee. Cultural status may present other challenges; women from some cultures, for example, may face special barriers to exercising in public.
Race has a direct bearing on health stresses and longevity in old age. A 65-year-old black American man can expect to live nearly 2 years less than a 65-year-old white American man (a pattern mirrored among black American and white American women). A person’s ethnic or cultural background and community context may substantially affect the outlook she or he brings to bear on a situation, the kinds of moderating activities she or he deems acceptable, and the importance she or he places on various outcomes. Older persons may understand disease through frameworks specific to other cultures, and treatment may need to include or rely principally on culturally centered options. A concept like autonomy that has become so central in issues of patient choice and advance directives has a different weight and value in cultures where choice belongs more to the community as a whole (as with some American Indian groups) or to a community or family leader (eg, in Hmong societies). Choices like hospice care may be viewed in some cultures as tantamount to wishing for and bringing about the death of the person. A procedure like autopsy may strongly violate cultural or religious beliefs. The clinician is advised to proceed attentively in cross-cultural situations. (See also Cultural Aspects of Care.)
Mediators shape a person’s responses to stress. They are the internal and external resources the person can bring to bear to assess and interpret the stress, to assess his or her own capacities for addressing it, and to formulate a coping response to it. Many key mediators are modifiable through psychosocial intervention. Instruction and information can affect the person’s understanding of a situation. Various forms of psychoeducation have been shown to be effective in enhancing an older person’s sense of mastery within a stress situation and in increasing his or her awareness and use of formal services. Family counseling and therapy can strengthen older person’s involvement with his or her social network.
A number of constructs have been studied that relate to a person’s sense of his or her own ability to manage situations. The concept of self-efficacy is comparable to concepts such as mastery, internal locus of control, resilience, and competence, and although it is singled out here, it resembles these in representing a key personal quality to be considered when dealing with an older person facing any stress situation. Self-efficacy is an important consideration for the mental and physical health of older persons for two reasons.
First, there is a relationship between strong or positive self-efficacy and a number of important health and mental health outcomes (Table 3.1). A large number of longitudinal studies—most notably the MacArthur study of “successful” or healthy aging—have produced a coherent set of conclusions about self-efficacy. The way a person approaches a situation—whether it be a specific threat, like the onset of an acute condition, or a more pervasive one, like change of life roles or decline in physical performance—affects the eventual outcome. Of particular note in Table 3.1 is the broad range of effects of strong self-efficacy beliefs, which influence physical and mental health as well as overall function. In addition, self-efficacy seems to contribute to a person’s ability to be actively engaged in life, an important moderating factor.
The second reason self-efficacy is important is that it is modifiable. It can be weakened by repeated assaults and poor outcome, but it can also be strengthened. Among the strategies effective for strengthening self-efficacy are the following:
A number of training programs aimed at improving specific performance (eg, reducing the fear of falling or increasing adherence to an exercise regimen following a heart attack) have succeeded by working to strengthen participants’ self-efficacy beliefs in the targeted area. Strong self-efficacy beliefs appear to be better predictors of performance than are measures of physical ability. In falls prevention studies, for example, those with strong self-efficacy beliefs related to falling were found to show reduced fear of falling, despite low objective measures for risk of falling. Self-efficacy appears to play an important role in coping and overall well-being in older persons. Clinicians should assess the older person’s sense of his or her own competence and intervene, where possible, to strengthen it.
A number of theorists have studied the manner in which older persons meet and address the accumulated challenges of aging. Cultivating an emotional response to a stressor can mediate its effect and produce a better outcome. Thus, invoking confidence and optimism in the face of bad news helps a person to meet the challenge and strengthens the likelihood of a positive outcome. One strategy older people may use consists of selection, optimization, and compensation. In this strategy, as people age, they begin to hone down the number and kinds of things in which they engage on the basis of what they believe they do well, selecting activities in which they are more likely to succeed. They also reframe the way they judge their own performance, looking, for example, at people their own age or older for a source of comparison. They do the selected things more, and they derive optimal credit for doing them. As losses continue and performance diminishes, people employ compensatory strategies that allow them to put their remaining performance capacities in the best light possible. A person known for preparing elaborate dinners might, for example, choose a simpler main course (selection) that she does well and has prepared many times (optimization) and surround it with numerous but very simple courses and side dishes as a way of favorably setting it off (compensation). Other coping strategies (eg, assimilation, accommodation, immunization, or resilience) also build essentially on the notion of reframing the self or one’s performance in order to provide positive reinforcement and to reinforce self-esteem. Clinicians should attempt to learn how their patients typically form successful responses to challenges and help them to address new challenges in these same terms.
Like people at all ages, older persons are faced with developmental tasks and challenges. In Erikson’s theory of staged development, the task of old age is integration—putting the pieces together in a way that both celebrates and continues to act on the learning and accomplishments of life. In this conception, and consistent with many other findings, involvement (sometimes termed productivity) plays an important role. Becoming more involved, actively seeking out ways to contribute to and participate in the broader world, even engaging in paid work are all mediators that can lead to better outcomes. Taking part, making a contribution—through volunteering, productive (sometimes paid) labor, active family roles (especially child care), and participation in group activities—are all associated with older persons’ continued well-being.
In terms of the framework of factors affecting health outcomes, social involvement can be understood as a positive, problem-focused coping response, a way of filtering the effects of a stressor by strengthening the connection of the person to the community (affirming the person’s value in the community). Older theories of normal aging saw disengagement—the systematic withdrawal of ties to the social world—as normative. In current thinking, however, such disengagement is not encouraged and might even be considered an abnormal behavior. At the very least, there is an association between lack of social involvement and affective disorders such as depression.
Moderators are components of a person’s life or behaviors in which the person engages that act to affect the demands of the various stressors he or she faces. Moderators may be in place before the onset of a stressor or they might be developed in response to it. A person who has a long history of exercise already has a good base of conditioning to deal with an emergent condition affecting mobility (eg, arthritis). Alternately, making a decision to begin to exercise, to control diet or alcohol consumption, or to cease smoking is a possible—and healthy—response to stressors ranging from the onset of illness to a realization that one has slowed down. These healthy behaviors directly moderate the effect of the threat or demand and contribute to better physical and mental health outcomes. Having a strong social network and calling on it in a time of crisis (rather than withdrawing) may help moderate age-related demands (for example the loss of a loved one).
The literature points to three major activities that moderate stress or demand and that appear to contribute to healthy aging: social involvement, spiritual or religious activity, and engaging in healthy behaviors. Older persons’ activities in these areas should be assessed regularly and encouraged, as appropriate.
The older person’s social network is a critical resource for overall well-being, and social isolation is a powerful risk factor for broad declines and mortality. The effect of their social networks on older persons’ overall well-being has been extensively studied, and the results of these studies are conclusive (Table 3.2). The literature points to the importance of quality over quantity but does not discount the latter. The closeness of social relationships is most important; thus, a well-functioning marital or familial relationship—a relationship that provides a person with a confidante—will offer the kinds of support and protection suggested in Table 3.2. Dysfunctional close relationships—those characterized by negative and conflict-filled interactions—appear to work in the contrary direction. The size of an older person’s social network appears to work in both directions. On the one hand, having a larger social network offers the opportunity for greater involvement and contribution; on the other hand, it presents the likelihood of experiencing a greater number of losses within the network (because of death or increased disability).
A robust social network both mediates and moderates age-related stresses. Social networks provide emotional and instrumental help in times of crisis. Families help older persons, for example, weather the death of a spouse or close friend, but they also provide direct and indirect help when more functional losses occur. The social network can provide a person under stress with a context within which to envision and frame responses to various demands. Social networks seem to exert a positive effect on older persons by strengthening their self-efficacy beliefs (the person feels valued within the social network, and this contributes to a sense of self-value). It also provides opportunities for taking action to address demands (eg, calling on family for specific functional assistance, spending more time with children following the death of a spouse, increasing time spent with friends following retirement).
The literature is clear that the provision of such help is positive and contributes to recovery, unless it sends the wrong message. Too much instrumental assistance provided to older people (particularly men) by the social network may contribute to continued disability. Rather than being encouraged to work toward restored function, a person may receive too much help or not be encouraged to self-care and may, therefore, accept a modifiable condition as permanent. Thus, although assistance from the social network should be encouraged, it should be done with attention to promoting maximum function by the person receiving the help.
Studies have consistently demonstrated two important facts about religion and older people. First, religion plays a more important part in the lives of older persons; older persons are more actively involved than younger persons in attending religious services and in carrying out regular private religious practices. More than 50% of older persons report frequent attendance at religious events (with little variation by gender or race). Second, there are consistent positive relationships between religious involvement and indicators of good health. Whether religious activity contributes to social integration, promotes involvement, or assists in the developmental tasks of aging, it seems clear that it is a positive force—at least for those already inclined to it.
Implementing positive behaviors (eg, exercise; controlling intake of food, tobacco, and alcohol; and active relaxation or stress-reduction techniques) have all been shown to have positive effects on overall well-being, no matter at what age they are begun. Although these are physical behaviors, they often rely on and benefit from strong psychosocial mediators, particularly self-efficacy and social networks. Clinicians should use these mediators when proposing older persons begin or strengthen healthy behaviors. It can help to invoke a person’s understanding of benefits and appreciation of his or her own proven ability to make change while at the same time offering suggestions about how the targeted behavior might contribute to a strong social network (eg, “you could walk every day with your daughter,” “you and your husband could take the healthy cooking class together”).
■ Aneshensel CS, Pearlin LI, Mullan JT, et al. Profiles in Caregiving: The Unexpected Career. San Diego, CA: Academic Press, Inc; 1995.
This book provides an excellent explication of the Pearlin stress model. It does so in the context of applying the model to the situation of family dementia caregivers. Valuable in itself, this application can readily be extrapolated to other caregiving and self-care situations, offering a more general model of stress and possible methods to intervene effectively.
■ Blazer DG. Self-efficacy and depression in late life: a primary prevention proposal. Aging Ment Health. 2002;6(4):315–324.
■ Fry PS, Debats DL. Self-efficacy beliefs as predictors of loneliness and psychological distress in older adults. Int J Aging Human Dev. 2002;55(3):233–269.
These two articles, in conjunction, illustrate the linkage among late-life stresses, a mediator and a moderator identified in the chapter (self-efficacy and spirituality), and an important late-life outcome, depression. The first article is one of many articles by this author detailing the issues that older people face with depressive disorders and the prevalence and incidence of these disorders among elderly persons. Of particular interest, this article offers a proposal for strengthening self-efficacy as a preventive technique against depression in older persons. The second article reports on a small study that documents the inverse association between spiritual self-efficacy and loneliness and psychologic distress.
■ Crowther MR, Parker MW, Achenbaum WA, et al. Rowe and Kahn’s model of successful aging revisited: positive spirituality—the forgotten factor. Gerontologist. 2002;42(5):613–620.
This article integrates the findings from many studies, establishing and delineating the importance of religion and spirituality in the lives of older persons and linking this important dimension of their lives to positive health outcomes.
■ Levenstein S, Smith MW, Kaplan GA. Psychosocial predictors of hypertension in men and women. Arch Intern Med. 2001;161(10):1341–1346.
This article reports on a cohort of 2357 adults followed since 1974 in the Alameda County longitudinal study. The article provides a good illustration of the association of psychosocial variables highlighted in the chapter—race, income, education, social status—with an adverse health outcome in later life.
■ Pinquart M, Sorensen S. Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: a meta-analysis. J Gerontol B Psychol Sci Soc Sci. 2003;58(2):P112–P128.
The literature on family caregiving for older persons is voluminous; this meta-analysis provides an overview of the strategies used to study and intervene with caregiver burden and depression and of the outcomes of these studies. The meta-analysis reinforces the concept that the outcomes of a stress process are multifaceted and subject to moderators and mediators. A good companion piece to this article is that by Brodaty H, Green A, Koschera A. Meta-analysis of psychosocial interventions for caregivers of people with dementia. J Am Geriatr Soc. 2003;51(5):657–664.
■ Rowe JW, Kahn RL. Successful Aging. New York: Pantheon Press; 1998.
This book summarizes the results of the MacArthur Foundation study of aging in America. This study followed a large cohort of healthy young-old persons over the course of several years. It identified a number of key factors that promote healthy or successful aging, most notably, social involvement and the maintenance of self-efficacy. The study has led to a number of more scientific presentations of results, principally in the Journal of Gerontology.
■ Smith J, Maas I, Mayer KU, et al. Two-wave longitudinal findings from the Berlin aging study: introduction to a collection of articles. J Gerontol B Psychol Sci Soc Sci. 2002;57(6):P471–P500.
This essay introduces four related articles emanating from the work of Paul and Margaret Baltes in the two-wave Berlin Aging Study. The overview essay and the subsequent findings quantitatively explore the selection, optimization, and compensation theory advanced by the Baltes to explain how older persons cope with the decrements in function that are associated with aging.
Kenneth W. Hepburn, PhD