Vicissitudes and Disappointments: Loss and Illness in Late Life
Pamela Melding
“Old age is not a disease—it is strength and survivorship, triumph over all kinds of vicissitudes and disappointments, trials and illnesses” in the words of the late Maggie Kuhn, civil rights activist (1). In historical times, longevity was greatly revered. People who attained old age not only had excellent survivorship but also were considered by their social groups to be a source of wisdom and cultural knowledge. Such accolades are not earned simply by reaching old age but accomplished! Old age is a major developmental period of the life cycle and one with more challenges, “vicissitudes and disappointments, trials and illnesses” to confront than at any other stage of life. Among these are changes to the physical self as organ systems become vulnerable to disease and decline. Simultaneously, older people have to confront the relational self as they retreat from the active world and their roles in the family and society change. Decline of the physical body and retreat from the active world allow time to confront the psychological self and bring the need to reminisce and put into perspective all of one’s life experiences, their personal value, meaning, and quality, in preparation of the final, ultimate retreat from life itself. Old age itself is certainly not a disease, and persons who successfully negotiate its challenges have the capacity for “strength, survivorship and triumph,” as Kuhn asserted. Successfully negotiating the challenges results in resolution
of emotional conflict, integration of experiences and achievements, and appreciation of contextual significance and meaning leading to psychological growth—the elements that are integral to “wisdom.” The reality for many women is successful aging—living and adapting well despite the problems of old age. But for others, old age can be a time of difficulty, in which triumph and survivorship seem to be an impossible dream. This chapter considers some of the challenges to overcome, the major “vicissitudes and disappointments” that can negatively influence mental health, and it looks at some of the important factors highlighted by aging studies as conducive to the “triumph and survivorship” of successful aging.
of emotional conflict, integration of experiences and achievements, and appreciation of contextual significance and meaning leading to psychological growth—the elements that are integral to “wisdom.” The reality for many women is successful aging—living and adapting well despite the problems of old age. But for others, old age can be a time of difficulty, in which triumph and survivorship seem to be an impossible dream. This chapter considers some of the challenges to overcome, the major “vicissitudes and disappointments” that can negatively influence mental health, and it looks at some of the important factors highlighted by aging studies as conducive to the “triumph and survivorship” of successful aging.
DEMOGRAPHY OF LATE LIFE
The changing population demographics around the world is possibly the most important factor influencing both physical and mental health of older women today. Increasing longevity and decreased fertility are the major causes of aging of the populations in most of the developed and developing world. Between 2000 and 2020, the population of people aged 65 and older is projected to rise rapidly in all countries of the world, with the greatest rise in the cohort over 80 years of age (2). The first countries to feel the impact of this change, Japan, the United Kingdom, Germany, and France, already have to deal with the issues as their elderly people now constitute 20% to 25% or more of their total populations. Others, such as Canada, the United States, Australia, and New Zealand, with elderly populations currently about 12% to 13%, have the benefit of a few years grace to observe how other countries deal with the challenges. The small surplus of males at birth is markedly reversed near the end of the life span because total life expectancy for men is several years less than for women. By age 75 years, women outnumber men by 4 to 3, and by age 80, there are twice as many women as men. This trend is more apparent in the most developed countries, where women have an additional 5 to 12 years of life expectancy, but even in less developed countries, women have greater longevity than men. Older women are more likely than men to be the recipients of retirement benefits, geriatric health care, and institutional care (2).
New Zealand is one of the Western countries that has still to see the impact of population aging. Yet in 2001 a New Zealand national census revealed that 3 of every 4 older men lived with others while only 1 of 2 women did. Twenty percent of men lived alone in contrast to 43% of women who did. While the majority of older men were married, fewer than half of older women were, and if both genders reached their 80s, half the men were likely to have still living spouses whereas only about 10% of women would have a partner (3). These demographics are consistent with similar findings for many other developed countries of the world.
VICISSITUDES, TRIALS, AND DISAPPOINTMENTS
POVERTY
A major consequence of being widowed is that income drops. The New Zealand census found that the median income for men over the age of 65 was more than the median income for women of the same age. Studies in other countries find similar trends. A British Household Study found that health in late life was substantially related to socioeconomic group and that elderly widows were disadvantaged
economically. Having poorer resources predicted poorer health and mental health (4).
economically. Having poorer resources predicted poorer health and mental health (4).
Poverty is a major social determinant of poor physical and mental health. Many women become impoverished for the first time in old age, after the deaths of their husbands. Many of the current generation of older women never worked in paid employment, or if they did, their working life was interrupted by child rearing. Those that had jobs outside the home were less likely to be educated beyond secondary school and more likely to be in low-paying or part-time employment. Consequently, financial security for many women came from being married. Older women are far less likely than older men to have either public or private pensions of their own. Many widows have to survive on the residual benefits of their deceased husbands’ pensions. These are often paid at a lower rate for the surviving spouse and rarely support the living standards the women had while their husbands were alive (5). Widows also lose a contribution toward fixed domestic costs such as property taxes, utility standing charges, maintenance, etc., and thus the discrepancies are larger than might be inferred from the statistics. State pensions (equivalent to Social Security benefits in the United States) barely cover living costs for those who have not contributed to private retirement investment funds, and personal savings diminish over time. Diet, heating, and housing resources can suffer, increasing vulnerabilities to health breakdown. In addition, worry over material resources can significantly undermine the psychological coping of the functionally limited disabled older person (6).
LOSS
Loss is the hallmark of late life. While losses can affect both genders, how they do so may be very different experiences for men and women. Many loss events in an older person’s life, such as retirements or bereavements are “on-time,” normative events that are anticipated and usually taken in their stride. Unanticipated life events, such as unexpected illness in self or spouse, the loss of an adult child, or natural disasters, are “off-time” events and have a more profound psychological impact. When a loss-inducing life event occurs in a person’s life, it can cause a change in circumstances, represent a threat, or be regarded as a challenge, and sometimes all three. Krause (7) postulated that the adverse impact of life events is more severe when an event threatens an aspect of self-image that identifies the person’s concept of a salient social role, such as spouse, parent, grandparent, friend, or contributor to the community. Older people subjected to several adverse life events in a short period are much more vulnerable to depression and poor psychological adjustment than others (8).
BEREAVEMENTS
Bereavements are common in late life. Indeed, some older people joke about funerals being their most common social experience. While they may take the deaths of friends and even spouses in their stride as normative events, the impact for long-lived females may be greater than just coping with the loss of dear companions. The loss of a male partner not only deprives a woman of a confidant and support but also changes her social and economic status. Although many older women do try to substitute for a lost partner or dear friend, these substitute ties often do not fully compensate (9).
Another consequence of women’s surviving longer than their male partners is that each gender has to deal with health problems in different contexts. In contrast to men, most of whom have partners and expect to be taken care of by that partner (10), most women are without partner support when they most need it. Recent widows may have a marked decline in their physical and mental health status (11). Consequently, women often become increasingly reliant on their social support networks as they age.
SOCIAL SUPPORT
The importance of social networks and their impact on health in late life should not be underestimated. A considerable body of research tells us that psychological and physical stressors may be moderated in older people if they feel cared for and esteemed by their social networks. In a classic London study, Murphy (12) found that older people with confiding relationships were less likely to have depressive illness following a threatening life event. Positive social support possibly may also have a direct effect on illness itself by enhancing immunologic function (13). Of course, the deaths of a spouse, siblings, and friends shrink the size and quality of an older person’s support network markedly.
A social network is defined as “those within the person’s larger social community who regularly provide support in a range of contexts of day to day life” (14). Social networks are a major source of assistance for older people; they may include (a) members of the same household, (b) relatives, (c) confidants, (d) people perceived by the person as able to provide necessary instrumental and emotional support. A social network enables a person to cope with life and its problems and provides access to resources that help from day to day (15).
Not all networks are strong enough to cope with the vicissitudes of old age. The quality of a support network is probably more important than its size, and discrete networks can respond in different ways to the problems of old age. Some are more robust in offering support to older people; others more vulnerable to breakdown under crisis. Wenger (15) argued that social networks have their own special characteristics and can be predictive both of types of health problems and of the response to them. Wenger developed a useful typology of social networks for older people, based on extensive qualitative research in Wales:
The local family dependent support network focuses on close family ties, often an old person living with an adult son or daughter. There are usually few neighbors and peripheral friends. The persons being cared for are more likely to be the old-old (i.e., over 80 years of age) and in poor health compared with those supported by other types of networks. They are more likely to be widowed and female.
The local family network is associated with older persons with dementia. In the old-old individuals commonly found in such networks, depression and loneliness tend to occur with increasing dependency along with fear of loss of autonomy and of being a burden (16). The caregivers looking after an elderly person may also be more vulnerable to stress and depression due to the increased burden of care.
2. The locally integrated support network is usually based on the long-term residence in one area of an elderly person who has maintained active involvement in community and church organizations over many years. The person supported
by this type of network has close relationships with local family, who live nearby, and with friends and neighbors. The network is often large, and because the network members often know each other, it can be very robust in times of crises when the network pulls together in collaborative action.
3. The local self-contained support network is one that supports an elderly person who has arm’s-length relationships or infrequent contact with at least one relative, often a sibling or a niece or nephew, but relies primarily on neighbors. The elderly persons tend to keep to themselves and ask for help only in an emergency. The relationships are undemanding, the person has lifelong resistance to reliance on others, and dependency is low.
The self-reliant people living in local self-contained networks often deny difficulties. They are often childless, and relatives are not a source of active emotional support (17). As a result of little interaction they may become subject to feelings of isolation and loneliness. They may also suffer from unrecognized physical and mental health problems.
4. The wider community focused support network is exemplified by the middleclass network of the retirement migrant. Typically, the elderly person supported by such a network has no relatives nearby but has active relationships with relatives, usually adult children, who live some distance away. Friends have high salience, and the relationships are characterized by a high degree of reciprocity, at least in the short term. People in wider community focused networks are usually educated and assertive, and they like to be their own case managers. They often go into residential care earlier rather than later if they begin to deteriorate.
5. The private restricted support network is associated with an absence of local kin, often childlessness, few nearby friends, and low levels of family or community contacts. Consequently, the network is generally very small. Contact with neighbors is minimal, and there is a low level of community contacts. These older people are often suspicious of others and deny any problems. They are more likely than others to resist medical and social interventions and to struggle to maintain independence against increasing odds. People with this type of support network are overrepresented among older persons with mental health and personality difficulties. Depression is often common, unrecognized, and undertreated. These older people may also adapt very poorly to residential care (15).
Poor economic resources, recent bereavements, social isolation, and impoverishment all carry increased risk for physical and mental disorders in late life (18). Deterioration of social resources for the older person or the inability of a social network to respond to a crisis is often the trigger for greater interaction with health care professionals.
PHYSICAL HEALTH
Of all life events, the most common ones to affect older people are illness stressors (19). Several studies of aging also indicate that illness and disability are the most stressful of all loss events. Physical aging can lead to deterioration in health status, often with resulting psychosocial ripple effects that limit independence, reduce self-determination, and induce a loss of self-esteem. Notably, chronic poor physical health and disability are major correlates of depression, prolonged hospitalization, suicide, and poor psychological functioning in old age (20).
Both sexes are, of course, prone to physical health losses. The leading causes of men’s earlier deaths are cardiac disease, stroke, chronic obstructive pulmonary disease (COPD), and cancer. However, because of their longevity, women are more prone to disabling diseases such as arthritis, osteoporosis, degenerative diseases of the brain, and hearing and visual impairments (21). Indeed, women have about two years’ more disablement than their male counterparts. These disabling diseases can last for many years, decreasing quality of life by causing persistent pain, restricting mobility, and reducing sensory enjoyment. Loss of visual and auditory acuity not only affects older persons’ sensory enjoyment of life but also negatively affects their confidence to manage basic activities of daily living and confidence to socialize and be involved in their communities (22).
Older people frequently experience multiple physical comorbidities. One physical disorder may tax an individual, but several comorbidities can be overwhelming (23). While physical debility may result from an acute change in health status, appetite, nutrition, or bodily rhythms may also be adversely affected. A disease may have secondary effects such as dehydration, metabolic or electrolyte upsets, severe pain or constipation, and the disease process may have a cascade effect, with one dysfunctional system putting additional strain on other marginal organ systems. Treatment may compound the patient’s problem through sedation or drug interactions.
Illness events have profound psychosocial effects far beyond the immediate physiologic impact. Illness, especially if accompanied by significant chronicity, pain, or disablement, has a major impact on the older person’s functioning, social roles, and relationships. A major insult to self-identity can occur when a person is no longer capable of taking care of himself or herself and becomes reliant on adult offspring or other caregivers. The “life of the party” may lose social confidence or suffer agoraphobia following a serious fall. Physical or cognitive impairment can force an elderly person to give up driving, limiting opportunities for social engagement.
PERSISTENT PAIN
More than 40% of older people report problems with pain or discomfort to some degree. The extent to which pain interferes with daily activities increases incrementally with age, women faring much worse than men (24). Many of the diseases affecting older women have disabling, persistent pain as a major feature (21). The list is long and includes arthritis, osteoporosis, vertebral collapse, sensory neuropathies from diabetes or ischemia, heart disease, stroke, trigeminal neuralgia, temporal arteritis, and more. Yet, despite acknowledgments from clinicians that pain is a symptom in all of these conditions, persistent pain in older people and particularly older women is underdetected and, worse, undertreated both in nursing homes and the community (25,26).
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