WORKING IN THE FIELD OF AGING:
CHALLENGES & OPPORTUNITIES
Patrick Arbore, Ed.D.
Director & Founder Center for Elderly Suicide Prevention and Grief Related Services
Institute on Aging, San Francisco, CA
1
Friendship Line – 800.971.0016
24-Hour Accredited Crisis Intervention Telephone
Hotline/Warm-line – Founded in 1973:
• Call-In Service – Confidential telephone discussions for
people 60+ (their caregivers or younger disabled) who
may be lonely, isolated, bereaved, depressed, anxious
and/or thinking about death or suicide
• A caller does not need to be in a suicidal crisis to use the
call-in service
• Mia Grigg, Friendship Line Director, [email protected]
• Patrick Arbore, [email protected] or 415.750.4133
2
Friendship Line
• Call-Out Service – Friendship Line Staff or Trained
Volunteers will make phone calls to older adults for
emotional support – Referrals can be arranged by calling
IOA Connect 415.750.4111
• Grief Services – Saturday Morning Drop-In Traumatic
Loss Group – 10:30 a.m. – Noon – 8-week Traumatic
Loss Grief Group and 8-week Advanced Traumatic Loss
Grief Group – Contact IOA Connect for more Information:
415.750.4111
3
NO EXPERIENCE IS LOST
"Aging is far from being only a process of reducing, wilting
and fading. Old age, like every other stage of life has its own merits,
its own magic, its own wisdom, its own sorrow. In the peak periods
of all cultures, old age was revered for good reasons. Today we
worship adolescence and we won't hold it against the young that
they see their phase as the best, but let us not believe this nonsense
propaganda that old age is worthless... Whoever becomes old
consciously, can observe that in spite of diminishing powers and
potencies, every year brings an increase and an enhancement in
the infinite web of relations and connections. As long as one is
conscious, nothing temporary, no past experience is ever truly lost."
-Hermann Hesse, The Seasons of the Soul
4
Aging
• We begin aging at birth
• The meaning of aging and those who are
identified as older adults are determined by
society and culture
• Aging is influenced by history and gender
5
January 2016 The Population Reference
Bureau report, "Aging in the United States"
• The number of Americans ages 65 and older is projected
to more than double from 46 million today to over 98
million by 2060, and the 65-and-older age group’s share
of the total population will rise to nearly 24 percent from
15 percent.
• The older population is becoming more racially and
ethnically diverse. Between 2014 and 2060 the share of
the older population that is non-Hispanic white is
projected to drop by 24 percentage points, from 78.3
percent to 54.6 percent.
6
Key Findings "Aging in the United States"
• By 2014, 23 percent of men and about 15 percent
of women ages 65 and older were in the labor
force, and these levels are projected to rise
further by 2022, to 27 percent for men and 20
percent for women.
• More than one-fourth (27 percent) of women
ages 65 to 74 lived alone in 2014, and this share
jumps to 42 percent among women ages 75 to
84, and to 56 percent among women ages 85
and older.
7
Sexual Minority Status and Aging
According to Teaster, White, & Kim (2016):
• There are approximately 1.4 to 3.8 million
LGBT elderly in the US
• By 2030, this number is expected to
increase to between 3.6 and 7.2 million as
the Baby Boomers age
Minority Status & Sexual Minority Status
• Because it has taken decades for evidence
to emerge (this population is often unseen),
data suggest that social isolation affects a
disproportionate number of older
individuals who continue to deal with
stigma, discrimination ageism, racism,
homophobia, and transphobia
Real Old Age
According to Jacoby (2011):
• Is it realistic to think that both a billionaire and a nonunion hotel maid ought to be able to save enough money to finance a 30-year retirement?
• Are doctors candid with people about their chances of survival after a specific treatment or procedure? What are the consequences of continuing aggressive medical treatment?
• Are our oldest elders capable of leading fully independent lives?
10
Retirement – According to James et al (2016)
• Current retirees are living longer than did
members of previous cohorts
• This “third age” is a time during which older
adults have new opportunities for self-
realization and fulfillment
• This new reality has left many older adults
wondering how they will live, what they will
do and who they will be for the next 20 to
30 years
11
Retirement
• For workers over the age of 55, the labor
force participation rate is up about 10%
compared with about 20 years ago
• Pre-retirees indicate a need or desire to
work past-conventional retirement ages
• Approximately 18% of non-retired
Americans aged 50 and older indicated that
they do not plan to retire at all
12
Key Findings "Aging in the United States"
• Demand for elder care will also be fueled by a
steep rise in the number of Americans living
with Alzheimer’s disease, which could nearly
triple by 2050 to 14 million, from 5 million in 2013.
• The large share of elderly also means that Social
Security and Medicare expenditures will
increase from a combined 8 percent of gross
domestic product today to 12 percent by 2050.
13
According to Data Compiled by the Social Security
Administration:
• Very advanced age will be the experience for
many of us
• Average U.S. life expectancy:
• A man reaching age 65 today can expect to live, on
average, until age 84.3.
• A woman turning age 65 today can expect to live, on
average, until age 86.6.
• And those are just averages. About one out of every four
65-year-olds today will live past age 90, and one out of 10
will live past age 95.
14
Life-Expectancy and Society
According to Moody and Sasser:
“A society in which life expectancy is believed to
increase at every age and in which one becomes
increasingly feeble as one grows older is a society
heading for trouble. …a society moving toward a
world in which there is little or no disease, and
individuals live out their natural life span fully and
vigorously, with a brief period of
infirmity…Dramatic changes in mortality patterns
result in equally dramatic social changes.”
Life-Expectancy Continued
• “The numerical increase in the size of the
aged population over the next 30 years will
mean that the number of older persons who
are dependent, disabled, and suffering the
functional consequences of multiple chronic
conditions will be larger than it has ever
been, far larger than most countries are
prepared to manage.” – Moody and Sasser
DE-PEOPLING THE WORLD
"Every person seventy-eight years old lives in
a somewhat de-peopled world. The trouble for me
is that I often loved people much older and wiser
than I. So I'm left now in the lurch, being, trying to
be, the old wise one and feeling like a great
goose."
May Sarton, Endgame: A Journal of the Seventy-Ninth Year
17
The report National Health Expenditure Data,
2015:
• NHE grew 5.8% to $3.2 trillion in 2015, or $9,990 per person, and accounted for 17.8% of Gross Domestic Product (GDP).
• Medicare spending grew 4.5% to $646.2 billion in 2015, or 20 percent of total NHE.
• Medicaid spending grew 9.7% to $545.1 billion in 2015, or 17 percent of total NHE.
• Private health insurance spending grew 7.2% to $1,072.1 billion in 2015, or 33 percent of total NHE.
• Out of pocket spending grew 2.6% to $338.1 billion in 2015, or 11 percent of total NHE.
• Hospital expenditures grew 5.6% to $1,036.1 billion in 2015, faster than the 4.6% growth in 2014.
• Physician and clinical services expenditures grew 6.3% to $634.9 billion in 2015, a faster growth than the 4.8% in 2014.
18
NHE Continued
• Prescription drug spending increased 9.0%
to $324.6 billion in 2015, slower than the
12.4% growth in 2014.
Real Old Age
• The most significant forms of impairment
are ADL disabilities (basic self care tasks,
such as bathing, dressing, getting in and
out of bed, eating) – physical or mental
decline prevents people from managing
important aspects of their lives
• ADL disabilities produced by dementia are
most strongly associated with the need for
institutional care
20
Instrumental Activities of Daily Living (IADLs)
• IADLs are tasks necessary to conduct the
business of daily life and also requiring
some cognitive competence, such as
telephoning, shopping, food preparation,
housekeeping, and paying bills
• The proportion of older adults with these
limitations rises sharply with age
21
Real Old Age
• More than 5 million Americans suffer from
Alzheimer’s Disease
• By the year 2050, there will be 13.4 million
Americans with AD
• There is no cure at this time
• Currently, AZD can be delayed but not
stopped
22
Real Old Age
• Older adults have one of the highest rates
of suicide
• Age related sensory changes affect one’s
view of self and one’s ability to relate to
others
• Substance abuse is a hidden epidemic
among the elderly
23
Denial of Aging
According to Gillick (2006): “When we
believe we will stay young forever, and
when we purchase special vitamins, herbs,
and other youth-enhancing chemicals to
promote longevity, we are engaging in
massive denial.”
24
Denial
• Americans spend an extraordinary $6 billion
annually on “anti-aging” remedies
• Aging (baby) boomers and their aging cohort take
pills and dietary supplements that purport to
prevent illness, cure diseases and promote long
life
• There is overwhelming evidence that the
remedies are ineffective at best, harmful at worst
– and a phenomenal waste of money
25
Physical Characteristics Associated With Older
People
• Wrinkled Skin
• Gray or White Hair
• Slow Movement
All of these assist rapid identification of
people based on their (old) age
The labels we give to these social
categories vary but include: old people,
elders, seniors, senior citizen and the elderly
26
People Watching
• What happens almost automatically when you
glance at people you pass walking down the
street? We tend to categorize people along three
dimensions – race, gender and age
• The study of racism has been and continues to
be a major focus of research
• Studies of prejudice based on gender are also
prevalent
• There has been comparatively little research
based on prejudice related to age (Nelson,2005)
27
Ageism
According to Butler:
“Ageism can be seen as a process of systematic stereotyping of and discrimination against people because they are old, just as racism and sexism accomplish this with skin color and gender. Old people are categorized as senile, rigid in thought and manner, old-fashioned in morality and skills…Ageism allows the younger generations to see older people as different from themselves; thus they subtly cease to identify with their elders as human beings.” p. 12
28
Ageism
• Although ageism is found cross-culturally, it is essentially prevalent in the US where aging is associated with depression, fear, anxiety, impotence, senility, impoverishment and unhappiness
• It is important for those who care for older people to be aware of their own attitudes toward aging and recognize how their beliefs may influence communication
29
Ageism Continued
• Ageism promotes the idea that older people
are a burden and this can lead to neglect
and social exclusion
• Ageism can reduce older people’s self-
esteem, reduce their participation in society
and restrict the types and quality of
services available to them
30
Facebook Study
A 2014 published study by Yale researchers on
content analysis of Facebook groups that had
descriptions about individuals aged 60 years of
age and older (mean age of group creators was
20-29 and no one > than 59) netted the following
results:
• 74% of the total descriptions harshly criticized
older people “they do not contribute to modern
society at all”
31
Facebook Study Continued
• 41% of the descriptions referred to physical
debilitation, 27% to cognitive debilitation, and
13% to both forms of debilitation
• An example: “I hate everything about them (old
people), from their hair nets in the rain to their
white Velcro sneakers. They are cheap, they
smell like {expletive deleted}…they are senile…
• 37% of the descriptions advocated banning older
people from public activities
• 26% of the descriptions infantilized older people
32
Facebook Study Continued
• In 37% of the groups, the creators
advocated banning older individuals from
various types of public activities
• Among the banning groups, driving was the
activity most frequently targeted (35%)
• THE MEAN AGE OF THE GROUP CREATORS
WAS 20-29 – Had a total of 25,489 members –
65% were men
Ageism in the Workplace
According to an AARP Study (2013), “approximately two-thirds of workers ages 45-74 state that they have seen or experienced age discrimination in the workplace. Of those, a remarkable 92% state that age discrimination is very, or somewhat, common”
34
Co-Occurrence of Ageism and Abuse
• The negative attitudes that lead to ageist
behavior also make it easier for the
perceiver to regard the welfare and
humanity of adults as less important than
that of younger adults
• As such, ageism may indeed be a
contributing factor that leads some younger
adults to neglect, exploit, or otherwise
abuse older adults
35
Ways In Which You Can Reduce Ageism
• Examine your own attitudes toward aging
• Gather information on facts of aging
• Avoid use of ageist terms
• Refuse to support those who discriminate
against older adults
• Join or support groups that oppose ageism
36
Modern Gerontology
According to Schachter-Shalomi (1995):
• M.G. treats aging as a problem of social engineering to be solved through technological means
• The one-sided drive to alter, reverse, or somehow control the biological process of aging actually impoverishes its meaning.
• So-called positive aspects of aging turn out to be disguised efforts to restore youth instead of appreciating growing old as a fundamental part of the human experience
37
A Future with Dignity
According to Al-Jen Poo (2015):
• We must achieve a profound cultural shift in how Americans feel about aging and care.
• Our new stories about care and aging must be told so that many different kids of people can relate to them on an emotional level
• Actually seeing older people as the complex people they are will be a huge relief for younger and middle-age adults who, consciously or unconsciously are plagued by unease about their own later years
38
Chronic Conditions
• Chronic illness is much more common
among the old than among the young
• Rates of chronic illness are 46%for those
>65 compared with only 12% for those <65
39
Question
How do older adults manage to accept
declines and losses yet still feel whole and
complete and anticipate death with calm
composure?
40
One Possible Answer
41
Spirituality and Religiosity
According to Gallup News Service (2012),
over 70% of Americans >65 said that religion
is very important in their lives – late life
increase in religiosity is modest, however
Challenges
• If the aging process reveals to us the
mystery of life, then life’s ultimate meaning
cannot lie in speed, consumerism, youth,
achievement, celebrity, and physical beauty
• The present situation of many older people,
old and young alike, has been described as
a disease of the imagination
42
Challenges
• Some people have accepted the negative images of old age, made them their own, and begun to live out of these images of incompetence and insignificance
• The task of a spirituality of aging is to convert the imaginations of both old and young to a new vision of the human
• This can only happen if the old themselves refuse to let society define them – and instead internalize new images of the later years
43
According to Ram Dass
• All people involved in spiritual traditions
agree that preparation for death is the
single most important spiritual practice
available to us throughout our lives
• In recognizing our own mortality, we are
forced to ask the question: Is there
something beyond this body? If yes, what is
it?
44
A Buddhist Perspective on Death
According to Pema Chodron:
• We are raised in a culture that fears death and hides it from us. Nevertheless, we experience it all the time
• We experience death in the form of disappointment, in the form of things not working out.
• We have endless moments to practice letting go, to learn about grieving, and to prepare for death
• We prepare for birth but for the miracle of death, we rarely prepare at all.
45
The Two Unfixables According to Dr. Gawande
• Aging
• Dying
The story of aging is the story of our parts.
The Meaning of Life
• For human beings, life is meaningful
because it is a story – A story has a sense
of a whole, and its arc is determined by the
significant moments, the ones where
something happens.
• In stories, endings matter p.
238-239
A Monumental Transformation
• People have an alternative to withering in old age homes
and dying in hospitals
• We’ve begun rejecting the institutionalized version of
aging and death
• No matter how miserable the old system has been, we’re
experts in it
• You agree to become the patient; the doctor agrees to try
to fix you despite the misery, damage, or cost p.
193
Courage in Aging and Sickness
There are at least two kinds of courage in
aging and sickness:
1. Courage to confront the reality of
mortality
2. The courage to act on the truth we find
Gawande wonders: One has to decide
whether one’s fears or one’s hopes are what
should matter most
Shaping Our Stories
• Our most cruel failure in how we treat the
sick and the aged is the failure to recognize
that they have priorities beyond merely
being safe and living longer; that the
chance to shape one’s story is essential to
sustaining meaning in life; that we have the
opportunity to refashion our institutions, our
culture, and our conversations in ways that
transform the possibilities for the last
chapters of everyone’s lives p. 243
Vital Questions
Where you or your loved one would prefer to
spend their last days? At Home? In
Hospice? In Hospital? Cultural/Ethnic
Considerations?
• Who will the person want to take care of
him/her?
• What kind of funeral services do they want?
• Do they want to be buried? Cremated?
Mental Health Concerns of the Dying
• People fear that their pain, symptoms, anxiety, emotional suffering, and family concerns will be lost
• In hospitals, many dying people receive unwanted treatment that prolongs pain
• Many patients fear that their wishes (Advanced Directives) will be ignored
• People fear that they will face death alone and in misery
• Anxiety and depression may result from the stress of the disease and fears about death
Death in the ICU
Based upon research from the Dana Farber
Cancer Institute:
• Was associated with 11 times higher rates
of post-traumatic stress disorder and 9
times higher rate of generalized anxiety
disorder among bereaved caregivers
• Hospital deaths were associated with 10
times higher rates of prolonged grief
disorder in bereaved caregivers
Advance Care Planning
• Average ACP conversation in hospital is 5.6
minutes with MDs doing most of the talking;
there is little exploration of patient values
• Medical perception is that patient’s don’t
want to talk about this
• Uncertainty regarding prognosis &
outcomes
• Perception that palliative care & aggressive
care are mutually exclusive
Advance Care Planning
• Unrealistic expectations on the part of the
physicians, patients, and caregivers
• Death implies “giving up” = “failure”
• Conversations happen too late, without
patient preparation, and at times when
patients and caregivers are at their “worst”
• Focus on procedures are unimportant –
patients are experts on personal values
End-Of-Life (EOL) Conversations
Principles:
• EOL conversations are about managing anxiety and decision-making
• Decisions require re-negotiation over time
• Patients need time to cope with anxiety
• Decision-making is a process
• Focus on what is important to the patient rather that on what is important to the physician
The Debate
• At root, the debate is about what mistakes
we fear most – the mistake of prolonging
suffering or the mistake of shortening
valued life
• Only a minority of people saved from
suicide make a repeated attempt
• The terminally ill who face suffering that we
know will increase, only the stonehearted
can be unsympathetic p. 244
Becoming Aware
• Become aware of your fears – Whatever the feeling you must go to the root of the emotion, which is a part of your personality that you do not know about, or are too frightened or ashamed to acknowledge
• We need to become aware because older age is a time for the cultivation of wisdom and integrity – older age is a time for going deeper into the self
Becoming Aware
• Recognize how your body feels when it
experiences the sensation of anger,
sadness, disappointment, joy, delight etc. –
speak with someone who will listen about
your “inner” experience
• If you do not challenge your negative
feelings, you will die with them – so change
an aspect of yourself now
Ability to Care for Oneself
1. What are the expectations and limitations for myself in this work?
2. What are the most stressful aspects of work with the old, the sick, the suffering, the dying and the bereaved?
3. What am I doing to help myself cope with the stressful aspects of my work?
4. What are personal warning signs indicating I am being stressed?
5. How do I nurture and replenish myself in this work?
Developing an Interest in Spirituality
According to Zukov:
• This begins with an experiment in trusting
• Trusting that your life is meaningful and that your experiences happen for a reason
• You must challenge your anger, jealousy, vengefulness, greed, and all other forms of fear
• It does not require blind faith or believing any expert or authority
Readings
Anderson, M. (2003). Sacred Dying: Creating rituals for embracing the end of life. New York: Marlow and Company.
Coutts, M. (2014). The Iceberg. New York: Black Cat.
Gawande, A. (2014). Being Mortal: Medicine and what matters in the end. New York: Metropolitan Books.
Jenkinson, S. (2014). Die Wise: A manifesto for sanity and soul. Berkeley: North Atlantic Books.
Joseph, E. (2014). In the Slender Margin: The intimate strangeness of death and dying. New York: Arcade Publishing.
Readings
Kalanithi, P. (2016). When Breath Become Air. New York:
Random House.
Katz, R., & Johnson, T. A. (eds). (2016). When
Professionals Weep: Emotional and countertransference
Responses in palliative and end-of-life care. New York:
Routledge.
Neumann, A. (2016). The Good Death: An exploration of
dying in America. Boston: Beacon Press.
Readings
Moody, H.R. & Sasser, J.R. (2015). Aging: Concepts and
controversies (8th ed).
Rosowsky, E. (2005). Ageism and professional training in
aging; Who will be there to help? Generations.
Currey, R. (2008). Ageism exists everywhere… Aging well,
vol 1.
Wink, P. & Dillon, M. (2003). Religiousness, spirituality, and
psychosocial functioning in late adulthood: Findings from a
longitudinal study. Psychology and aging, 18(4).
Readings
Harley, D. & Teaster, P., (eds). (2016). Handbook
of LGBT elders: An interdisciplinary approach to
principles, practices, and policies. N.Y.: Springer.
Jahn, D., Poindexter, E.K., Graham, R.D., and
Cukrowica, K.C. (2012). The moderating effect of
the negative impact of recent life events on the
relation between intrinsic religiosity and death
ideation in older adults. Suicide and life-
threatening behavior, 42(6).
Readings
Reiff, D. (2008). Swimming in a Sea of
Death: A son’s memoir. New York: Simon &
Schuster.
Schillace, B. (2015). Death’s Summer Coat:
What the history of death and dying teaches
us about life and living. New York: Pegasus
Books LLC.