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Chapter 1
INTRODUCTION
Anne McIntyre and Anita Atwal
Ageing is a process that occupational therapists cannot ignore, for globally there will be 1.2 billion people over the age of 60 by the year 2025, and by 2050 these figures will have doubled, with 80% of older people living in developing countries (WHO 2002). However, instead of considering increasing life expectancy as a success story it is commonly viewed with doom and gloom, often associated with the belief that old age equals dependency, requiring more money to pay for additional health and social care. Yet healthy older people should be considered a precious resource, making important contributions to their families, communities and the economy at large, by either paid or voluntary employment (WHO 2002). Butler (1975:12) who first used the term āageismā suggests that we have a ādeep and profound prejudice against the elderly. Such attitudes need to be challenged and eradicated.ā This is of particular importance to occupational therapists, for as a profession, we have a core role to enhance occupational performance utilising client-centred rehabilitation and health promotion techniques.
The ādoom and gloomā approach to older people can be traced to relative unglamorous background of older peopleās medicine. The original role of the geriatrician was to manage the patients of the chronic long-stay institutions, with no access to the general hospital. This changed following the work of Marjory Warren in the 1930s, who demonstrated that older people who resided in workhouses had treatable diseases that responded well to rehabilitation. In 1947 the British Medical Association recommended that specific geriatric units should be set up to treat older people. The word āgeriatricā was created by Igantz Nascher in 1906 whose initiatives inspired social and biological research on ageing (Grimley-Evans 1997). Since then different names have been used for older peopleās services, such as ācare of the elderlyā or āgeriatricsā. These terms are seen as demeaning and imply that older people need to be cared for. Consequently throughout this book the term āolder peopleā will be used to reflect the spirit of current health and social care background.
Indeed the unglamorous and low prestige of older peopleās services has resulted in many professionals (including occupational therapists) not wanting to work within this speciality. This book aims at moving away from depicting old people as a problem and from the attitude that society gains little from older people. This ethos is reflected in the term āactive ageingā adopted by the World Health Organisation (WHO 2002). Active ageing signifies an important paradigm shift: that is away from a needs-based approach to a rights-based approach, which support the rights and continued participation of older people both in the community and the political process (WHO 2002). One document which reflects the ethos of active ageing in the United Kingdom (UK), is the National Service Framework (NSF) for Older People (DH 2001a). This document has helped to revolutionise the way in which older peopleās health is managed and the way in which the occupational therapist will work for the next ten years.
Box 1.1
What is active ageing?
āThe process of optimising opportunities for health, participation and security in order to enhance quality of life as people age.ā
(WHO 2002:12)
What is ageing?
Describing a person as old because they are 65 is simplistic and convenient, when clinical experience and research tells us that older people vary considerably in their abilities and outlook, with many 75-year-olds having a younger attitude than those years their junior. The NSF for Older People (DH 2001a) has also recognised that older people are not a homogenous group and suggest that older people could belong to three broader groups ā
- Those entering old age.
- Those in transition between healthy old age and frailty.
- Frail older people.
However chronological age is commonly used as a basis for entry into or exit from many services, screening and investigations and it is considered that such age discrimination should not continue.
Ageing is inevitable and how and why we age has been scrutinised by many over the centuries. More recent theories are of interest as they will impact on how older people perceive themselves and how they are perceived by their families, health and social care professionals and society. Biological ageing could be said to begin at conception (in utero) or from the age of 30 when physiological decline becomes more apparent. Past theories of biological ageing have considered that an organism is programmed to live for a set period of time (for example four score years and ten), with an āageingā gene that determines when we will die (Hayflick & Moorhead, 1961). However not all structures and functions deteriorate at the same time or rate. The more recent evolution theory considers that organisms are genetically programmed to live rather than die (Kirkwood 2002). Kirkwood (2003) suggests that our survival is determined by 25% genetic inheritance and 75% by lifestyle, such as nutrition, physical activity, freedom from disease and trauma, as well as living and working in healthy environments. Evolution theory considers that ageing occurs because of an accumulation of mutations within cells because of oxidative stress caused by the presence of free radicals. The speed at which cells become defective will be affected by our genetic inheritance, lifestyle, or environment (Kirkwood 2002). This theory suggests that ageing is to some extent malleable and within our control. Such malleability is also considered with the co-existence of disability with older age. Other theories consider that disability is not caused by ageing, but strongly associated with it, and that healthy lifestyles can delay the onset of disability, compressing morbidity into fewer and later years (Fries 1980).
Not all theories are concerned with biological ageing. Psychological ageing is considered to occur at any time, involving the concepts of maturity, wisdom and senility. Not all functions are said to deteriorate with age, with experience and acquisition of knowledge increasing whilst reaction times decline (Woodruff-Pak 1997). Aspects of social ageing also vary. It is evident that many older people are disadvantaged by social class inequalities, in terms of life expectancy and successful ageing, in both the UK, and elsewhere in the world (WHO 2003). Changes can be experienced by the individual in terms of change of role and relationships within the family and work, in terms of both positive and negative attitudes within their social environment. Sociological theories encompass:
- Eriksonās theory of psychosocial development (1950). Older people reach the stage of āintegrity versus despairā, where they are able to accept their past life and prepare for death.
- Disengagement theory (Cumming & Hurry 1961). Older people turn inward, withdrawing from society and family in preparation for death. This eases the way for the eventual loss of the older person and leaves the way free for younger people. This is more noticeable in terminal illness and also āabandonmentā of the older person in residential care far away from family and friends.
- Activity theory (Neugarten et al. 1968). Successful ageing, happiness and fulfilment occur as a result of participation in social and family activities.
Professional and personal attitudes to older peopleās activity and participation will vary according to the theoretical stance on ageing adopted. For example, if we view ageing as an inevitable decline in all functions from our 40s onwards, the expectations of activity and participation in a 70-year-old will be less than that of a 50-year-old. However, as many older people (including those considered as āthe oldest oldā) live highly active lives ā in sport, in full-time employment, as volunteers, carers and in lifelong education, their lifestyles support evolution, compression of morbidity and activity theories in that body functions and systems can be maintained and optimised by regular physical, cognitive and social activity. The following chapters reinforce that a great variability (or heterogeneity) in occupational performance can be observed in older people. It is therefore important not to assume a decline in functioning in all older adults of the same age, but to consider each person as an individual, as dictated by core occupational therapy client-centred values.
Box 1.2
āThe word active refers to continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or participate in the labour force.ā
WHO (2002:12)
Active ageing
Current thinking considers that client- (or person)-centred policies and services should focus on active ageing (WHO 2002), otherwise described as āsuccessful ageing and living well in later lifeā (Wistow et al. 2003), with successful ageing entailing control and interdependence (empowerment) rather than choices and independence.
Research of successful ageing points to a proactive and promotional approach, rather than a slowing down of inevitable decline. These approaches mean that occupational therapists need to be more aware of the health promotional aspects of their interventions and reinstate rehabilitation programmes. Older people give successful ageing a multidimensional definition, including physical and psychological health (being disease-free), functional health and social health (active engagement with life) (Phelan et al. 2004). What is of overriding interest and should have impact on occupational therapy, is that social and productive activities in older life reduce mortality risks as much as fitness activities (Glass et al. 1999). The evidence for such behavioural interventions continues to strengthen, with Cassel (2002) suggesting that continued social, physical and mental activities should be combined with biomedical and pharmacological interventions to enhance physical and mental health and capacity, thus changing how health care is organised and delivered.
It is therefore important that old age is not medicalised and treated as a disease. However many older people do see disability in older age as inevitable, having more negative perceptions of themselves and older age. Such negativity leads them to have low expectations of themselves and services, dismissing declining body functions and activity participation as part of old age, rather than part of a new and treatable disability (Sarkisian et al. 2002). These negative attitudes of older people and society need to be carefully monitored and altered as part of a wider prevention scheme.
Another aspect of successful ageing and living well in later life is that of ādying wellā or a āgood deathā (Wistow et al. 2003). Person-centred care is just as necessary in dying as it is in life and it has been argued that death has been medicalised in the same way as old age has been, so that death is seen as a failing of medical science rather than as a certainty (Smith 2000).
Box 1.3
Age Concern produced a Policy Position Paper titled āEnd of Life Issuesā (Age Concern 2002). This discusses death and dying in older age, including current public policy, and can be accessed on:
http://www.ageconcern.org.uk/AgeConcern/media/EndoflifepppSept2002.pdf
Challenges for occupational therapy
Health promotion
Much of what determines successful or active ageing fits perfectly within the occupational therapy philosophy of Occupation; that is the ādoingā to enable health and wellbeing. However, the role of occupational therapy within health promotion still needs to be further developed. In the UK, this role has been directly influenced by Wilcock (1998, 2002) who sets out strong arguments for the role of occupational therapists as health promoters in the public health arena. Her main proposition is that occupational therapy must extend beyond the amelioration of illness and become directly involved with the promotion of optimal states of health in line with health-promoting philosophies (see also Chap...
