Ageing and Older Adult Mental Health

Issues and Implications for Practice

Patrick Ryan, Barry J. Coughlan, Patrick Ryan, Barry J. Coughlan

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415582902
• eBook ISBN: 9781136708893
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This book examines the issues and implications that mental health professionals face when dealing with ageing and older adults. The book focuses on the biological, psychological and cultural influences that impact on the work of mental health practitioners who work with this client group.

Based on current empirical research and evidence-based practical issues this book explores topics including:

• ageing and dementia
• elder abuse
• caring for older adults
• depression and ageing
• the paradox of ageing
• how older adults are key to the success of future generations.

Throughout the book the contributors emphasise the notion of 'healthy ageing,' and the importance and significance of this concept as part of the life-cycle process. As such Ageing and Older Adult Mental Health will be key reading not only for mental health professionals, but also for those involved in policy making for older adults.

Chapter 1

Ageing

Historical and current perspectives

Patrick Ryan, Lena O’Rourke, Marcia Ward and Cian Aherne

Introduction

Many authoritative accounts of the process of working therapeutically with older people have been generated, debated, agreed and argued over. The aim of this chapter is to orientate the reader to various influences on the construct of ageing that are fundamental in understanding how this group is viewed in modern thinking. Such components will include current demographic changes in society, different forms of ageing and relevant theories that have evolved from both a historical and current understanding of what the term ageing actually refers to.

What is ageing?

Ageing may be viewed as the accumulation of changes in an organism or object over time. Biologically, ageing is defined as a deteriorative process, a fact that has almost become the very definition of ageing in current thinking. In humans though, ageing refers to a multidimensional process of physical, psychological and social change. Some dimensions of ageing grow and expand over time; whereas others decline, e.g. reaction time may slow with age whereas knowledge and wisdom may increase. Research shows that late in life potential exists for physical, mental and social growth and development. This could be termed as ‘successful ageing’ as it refers to optimal physical, psychological and social possibilities for living. It points to an experience of ageing where health, activity and role fulfilment are better than supposedly found within the population generally (Rowe & Kahn, 1997). Ageing therefore is part of what makes up society and it captures not just biological changes that occur across the lifespan for people but also reflects the prevailing cultural and societal conventions related to growth and development that a particular person experiences at a given time.

Demographic changes in society

We are led to believe that we live in an ageing society and actuarially this seems to be the case. In the developed and developing world, people are living longer, and increasing longevity across societies is both a major societal achievement, and a challenge (World Health Organization [WHO], 2002). A combination of low fertility rates and increased life expectancy has resulted in the relative ageing of societies worldwide. The United Nations Department of Economic and Social Affairs (2004) reported that 5.2 per cent of the world’s population was over the age of 65 in 1950, and that this had risen to 6.9 per cent by 2000. Furthermore, it predicted that this percentage would reach 15.9 per cent by 2050 and 24.4 per cent by 2100. Overall, a 238.4 per cent increase in the number of older adults globally is projected between 2000 and 2050. In more developed regions, people over the age of 65 make up 14.3 per cent of the population in 2000 and this will increase to 25.9 per cent by 2050. In Ireland, the Central Statistics Office (2004) predicted that the population would grow from approximately 430,000 in 2001 to between 1.119 and 1.146 million in 2036 – thus more than doubling in size over a space of 35 years. In the UK, the Office for National Statistics (2009) found that the percentage of the population aged 65 and over increased from 15 per cent in 1983 to 16 per cent in 2008, an increase of 1.5 million people in this age group. It also predicted that by 2033, 23 per cent of the population will be in this age group. In the European Union (EU), Giannakouris (2008) found that the percentage of the population aged 65 and over is projected to increase from 17.1 per cent (84.6 million) to 30 per cent (151.5 million) by 2060. Statistics also show that in developing countries the demographic transition occurred much faster than developed countries. In France, it took 120 years for the proportion of elderly people to increase from 7 to 14 per cent. Developing countries like China, Malaysia, Jamaica, Brazil and Thailand will have had a doubling of their older adults from 7 to 14 per cent in less than 30 years (Global Health through Education Training and Service, 2005).

It is the oldest old segment of society (people aged 85 years plus) that shows the most dramatic increase in numbers with a five-fold increase from 69 million in 2000 to 379 million older people in 2050. It is estimated that over the next 50 years the numbers of people aged 90 and above will show an eight-fold increase, but the number of centenarians will show the greatest increase in numbers as the number of people aged 100 and above in 2050 will be 18 times greater than the numbers in 2000. The fastest population increase, in the UK, has been in the number of those aged 85 and over. Since 1983, the number of people in this age group has more than doubled from 600,000 to 1.3 million. By 2033 the number of people aged 85 and over is projected to more than double again to reach 3.2 million, and to account for 5 per cent of the total population (Office for National Statistics, 2009). The number of people aged 80 years or over in the EU is projected to almost triple from 21.8 million in 2008 to 61.4 million in 2060 (Giannakouris, 2008). Interestingly, the growth of the oldest-old section of society is also a feature in developing countries and the absolute numbers of older people in developing countries is increasingly marked (WHO, 2002). So the concept of the ageing society seems valid but somehow is also presented as having problematic resonances that society will struggle with. Why that is and how it influences working with this age group will be a question that permeates the chapters that are to follow.

Chronological ageing

Chronological ageing, referring to how old a person is, is arguably the most straight forward definition of ageing. The differentiation between middle age and old age at the age of 65 was first postulated by Bismarck in Germany in the 1880s, when formulating social policy for the country (Butler & Lewis, 1973). It has since been used as a benchmark for the age of retirement and eligibility for social benefits. Levinson (1978) identified the early sixties as the period when middle adulthood ends and late adulthood begins. Bromley (1988) distinguished between the ‘young-old’ (65–74 years) and the ‘old-old’ (75 plus years). A different perspective of ageing was proposed by Birren and Schaie (1977) who introduced the concept of functional age as an individual’s level of capacity to fulfil given roles relative to others of similar chronological age. However, the age of 65 has limited, if any, relevance as an indicator of functioning, such as general health, mental capacity, psychological or physical endurance or creativity (Butler & Lewis, 1982). Western society assumes that there is general deterioration in adults in all of these areas of life once the demarcation age of 65 has been reached. This assumption is so thoroughly embedded in popular thinking that it rebuffs the daily living evidence that undermines it with ease. Such an assumption does not serve Western society well as it builds itself on the distorted notion that all that is good and desirable is only to be found in young people. Ageing has become almost solely defined as a negative, wearisome process that drains from the good in society when in fact it is the only developmental process that people experience from the moment of conception. From that moment, we are all ageing.

Biological ageing

Victor (1987) outlines that biological ageing is an estimate of the impact of ageing upon physiological systems. It provides a physical basis for ageing. Similarly, Aiken (1999) postulated that biological age is the anatomical or physiological age as determined by changes in organismic structure and function (encompassing structures such as skin texture, hair colour, mobility, etc).

Various hypotheses have been proposed to account for biological ageing such as wear and tear theories (Perlmutter & Hall, 1992). The three most common are the deoxyribonucleic acid (DNA) repair theory (Perlmutter & Hall, 1992), the cross linkage theory (Bjorksten, 1974) and the free radical theory (Harman, 1968). The DNA repair theory proposes that repair of DNA cannot keep up with the damage from metabolism, radiation or contact with pollutants. The cross linkage theory holds that the cross linking of large intracellular and extracellular molecules causes connective tissue to stiffen. These highly reactive molecules, or parts of molecules, may connect with and damage other molecules. The free radical theory is based on the fact that free radicals damage membranes by working on unstructured fat in them.¹

Four other theories of ageing are also proposed (Busse & Blazer, 1989). These include the immunological theory, the exhaustion theory, the ageing clock theory and the biological programming theory. The immunological theory suggests that with time there is a waning level of immunoglobin in the body that results in lowering the older adults’ immunity and makes them more susceptible to disease and infection. The exhaustion theory proposes that a definite amount of energy is available to the body and that this eventually becomes exhausted. The ageing clock theory, as the name suggests, posits that a ‘clock’ resides in the hypothalamus in the brain and cell loss in this area results in a decline of homoeostatic mechanisms with age. Finally, the biological programming theory suggests that cells are genetically programmed to have a certain lifespan. However, it must be concluded, as posited by Busse and Blazer (1989), that a convincing and empirically validated theory of old age simply does not exist.

Regardless of the underlying cause, certain biological changes occur in specific systems in old age. These include the changes in the skeletomuscular system that result in a general decline in strength. Muscle cells are replaced by fat cells and bones become thinner. Height can be reduced due to atrophy of the discs between the spinal vertebrae, a general atrophy of bones and skeletal atrophy. Changes occur in the skin due to loss of hydration and are often the most obvious manifestations of the ageing process. Metabolic and structural changes occur in the eyes, which lead to a deterioration in vision and eyeball mobility. The ability to focus at different distances may be reduced owing to loss of lens elasticity (Stuart-Hamilton, 1994) and the pupil decreases in size (Perlmutter & Hall, 1992). Such changes are evidenced in behavioural manifestations. For example, impaired vision affects driving. The American Psychological Association (1994) found that impaired vision affects driving and driving is often seen as the primary source of mobility for older adults. Therefore maintenance of driving becomes a primary mediator in the focus to maintain independent functioning. It is proposed here that rural populations in general share this belief but unfortunately it is well-known that transport links and infrastructure is indeed limited and inadequate in rural parts of even the most developed countries, thus decreasing social interaction.

Increased physical incapacity and hearing loss also appear common in old age. However, the effects of decreased physical incapacities are not as difficult in familiar surroundings. Older people with failing eyesight are less likely to be afraid when they know the layout of a house and where assistance may be maintained. It is also easier to engage in an activity if it has been established as a routine. Hence, the effects of decreasing physical capabilities may be lessened in a familiar and appropriate environment. Hayflick (1977) and Gueli et al. (2005) concluded that disease rather than biological ageing is the more common cause of deterioration in old age. As a direct result, the older adult population will require access and increased input from both primary and secondary care services.

Although much of the discussion thus far considers particular difficulties that emerge in old age, the general picture is bright, with four out of five older adults being fully mobile. The overall physical health of the body plays a critical role in determining energies and adaptive capacities of older people. Adults in later life are not as anxious, depressed or fearful as might have been expected (Kunzman et al., 2000; Thompson et al., 1990) and as such have much to offer to the generations coming behind, a theme explored in Chapter 15.

Sexual ageing

Renshaw (1996) noted that disbelief, humour and neglect have all been associated with the expression of sexuality in the older adult. In the famous Kinsey reports (Kinsey & Pomeroy, 1948; Kinsey & Gebhard, 1953), only two references address issues with men over 60, whereas women over 60 are mentioned in a meagre half a page. Belsky (1990) observed that negative stereotyping of older adults includes an evaluation of the unattractiveness and inappropriateness of sexual behaviour within this age group. This may prevent older adults disclosing information on their sexual lives. Another possible reason for non-disclosure may be that older adults may not be accustomed to speaking about their sexual lives given that they grew up in an era where such matters were not freely discussed (Stuart-Hamilton, 1994).

Sexual desire remains active throughout life, even if only expressed in fantasy. Winn and Newton (1982) found that in over two-thirds of 106 different societies, older males had a negligible loss of sexual interest, with the figure for continued interest for females (84 per cent) even higher. This view was initially reported by Pfeiffer (1974) who purported that sexual capacity continues for the majority until extreme old age, and in some individuals can continue into the nineties. Masters and Johnson (1966), imminent sexologists, found that although sexual responsiveness weakens in the male after the age of 60 years, regularity of arousal, adequate physical well-being and a healthy mental orientation to the ageing process provide a climate conducive to sexual performance that may extend up to and beyond the age of 80 years. Chew and colleagues (2009) found that one-third of men above 65 years of age and one-eighth of men above 80 years of age, in an Australian sample, had experienced sexual activity in the preceding 12 months; 11 per cent and 3 per cent of these, respectively, experienced sexual intercourse on a regular basis. However, 50 per cent of these sexually active men had erectile dysfunction problems.

Lidz (1983) confirmed that older people remain sexually active into advanced old age. The male becomes less potent but not impotent. There is a difference of opinion regarding female sexual response. Corby and Solnick (1980) concluded that female sexual response did not change with age. Masters and Johnson (1966) found that the intensity of physiological reaction and response to sexual stimulation were both reduced with advancing years. The value of seeing sexual experience as more than just sexual behaviour was highlighted by Butler and Lewis (1982) when they broadened sexual activity to include the opportunity to explore personal value systems in relation to loyalty, passion, self-affirmation and relationship with the physical self.

Psychological ageing

Psychological ageing is the capacity of individuals to respond and adapt to their changing environment. Birren and Schaie (1977) asserted that psychological ageing involves th...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• List of tables
• List of figures
• List of contributors
• Acknowledgements
• Introduction
• 1. Ageing: Historical and current perspectives
• 2. The biology of ageing: What works, what slows, what stops?
• 3. Ageism: Myth or fact?
• 4. Assessment of mental health issues: Approaches and frameworks
• 5. Treatment of mental health issues: Reality versus best practice
• 6. Ageing and dementia: Assessment and intervention
• 7. Older adults’ experience of loss, bereavement and grief
• 8. Depression and ageing: Assessment and intervention
• 9. Elder abuse: Understanding pathways and processes
• 10. Elder abuse: What works and does not work to prevent it?
• 11. Ageing and attachment
• 12. Ageing, relationships and sexuality
• 13. Caring for older adults: Who cares and who does not?
• 14. The paradox of ageing: Why do older people look so happy when they have nothing to look forward to?
• 15. Older adults: Key to the success of younger generations
• Index