Growing old was once considered a downward spiral, but opinions are changing with evidence showing that many people can maintain healthy and fulfilling lives long into old age. InPsych feature writer Sarah Ford reports.

As more is discovered about the process of resilience in ageing, the more apparent it is becoming that various psychosocial interventions can be employed to promote healthy ageing. Dr Nancy Pachana, Deputy Head of the School of Psychology at the University of Queensland, is a clinical psychologist and a neuropsychologist who has worked with older adults (age 65 plus) for over a decade. Also the Chair of the APS Interest Group on Psychology and Ageing, Dr Pachana says there has been a recent shift in the research focus and public perception on ageing. A former emphasis on disability and loss is being replaced with an investigation into the strengths unique to older adults and how functioning can be maintained for as long as possible, she says.

"Older adults bring with them a lifetime of experience and this can be applied to difficulties that come up later in life." For example, older adults often cope better with the loss of a spouse than younger adults because late adulthood is the expected time for such a loss to occur, with friends often in similar situations. In comparison, younger people may find themselves isolated and lacking in coping resources. Many older adults also demonstrate resilience despite decreasing social networks. There is a perception that they lack social support because their friends are dying. But, even though the amount of social contact lessens with age, great satisfaction continues to be derived from those remaining, long-standing interpersonal relationships.

Keys to ageing well

Clients often ask Dr Pachana how to promote successful ageing. She says the main goal is to maintain good physical health, which in turn boosts psychological health. "It is best to be mindful of that from an early age but even if people, for example, give up smoking relatively later in life, they can still realise real health benefits." The second key to successful ageing is maintaining mental activity, Dr Pachana says. "There are a lot of studies out now showing protective affects of maintaining social support networks, hobbies and interests later in life." Research shows that it is doing the activity, rather than the type of activity, which is important. "People who have few interests and a small social network are at greater risk of unsuccessful ageing. They are more likely to become isolated, depressed and anxious, and to lack resources to call on if things don't go well."

Research has found that a person's self evaluation affects their mental health, especially in later life. Dr Pachana says that more positive self evaluations can assist people in life transitions, and have been found to be prevalent among those who live past 100 years of age. In studies on centenarians, many say they are "not too hard on themselves" or that they are easygoing in their approach to life. "Perhaps this is a key part of resilience, and a longer and happier life," Dr Pachana says.

Predicting longevity

There are numerous ways to define resilience in ageing. One method is to classify people according to their physical, cognitive and social functioning. Researchers have operationalised these domains to determine high, medium and low degrees of successful ageing. Another method, employed by Professor Mary Luszcz and colleagues at Flinders University in Adelaide, is to examine the longitudinal research on ageing.

Prof Luszcz, a Professor of both psychology and gerontology, and colleagues at the University's Centre for Ageing Studies, have for 13 years been tracking 2000 participants who were aged 70 or older at baseline. Most participants are living independently within the community, with only a handful in residential care. A key aim of this research, called the Australian Longitudinal Study of Ageing, is to identify predictors of healthy ageing, which will in turn inform interventions to promote healthy ageing. Results so far suggest that this group of older Australians are ageing well.

Prof Luszcz says that to date several psychosocial factors have been found to be risk or protective factors for mortality. In one study, participants' depressive symptoms were assessed over three years and it was found that while more women experienced depression than did men, the impact of the illness was greater for men, especially those who developed it during that period (Anstey & Luszcz, 2002a). Gender and mortality have also been found to interact in research on participation in social activities or groups. Women who were involved in activities had a significantly longer life expectation than women who weren't, but the effect was not found for men (Anstey & Luszcz, 2002b). Prof Luszcz says this may be associated with women's tendency to be more nurturing, caring and active in social settings. "Women tend to be the carriers of the social relationships that exist around the whole family", she says. "But, considering we are looking at people over the age of 70, there may be also an element of generativity, or wanting to care and nurture future generations. Some of the groups they participated in were voluntary, involving doing things for others."

In comparison, men tend to be more solitary in their activities. It may be that they are more content to stay at home and occupy themselves. However, Prof Luszcz says this doesn't mean that men don't value social interaction, a view that is supported by further examination of the depression results. "When we looked at the depression finding more closely it wasn't that the men had recently been widowed, for example. Rather, experiencing depression later in life may be associated with increasing frailty and illness, and perhaps reflecting on one's own mortality. It may be that the social interactions that women have buffer them from that effect. But we don't have much information on participants before they were 70, so it may be that women have developed better coping strategies early in life which continue to serve them well as they get older."

A sense of control and optimism (the latter measured by the participants' perceived likelihood of living for another ten years) was found to be a strong negative predictor of mortality for both genders in the longitudinal study. "People who thought they would live longer actually did live longer," Prof Luszcz says. "This is likely to be indicative of a person still looking forward and planning ahead."

In research on social networks, Prof Luszcz and colleagues have found that the composition of networks was a key predictor of longevity. By separating networks into family, friends and spouse, it was found that participants who maintained a reasonable number of non-family supports were likely to live longer (Giles, Glonek, Luszcz, & Andrews, in press). Prof Luszcz says this is associated with remaining active and exerting a certain amount of control over your interactions. Acceptance is another key variable to ageing well. Acceptance involves acknowledging that you are an older person with limitations, but getting on with things rather than dwelling on regrets or former superior functioning.

Determining the role of psychosocial variables in this research has meant controlling for numerous physical and biological factors, such as participants' number of illnesses, medications, and self-ratings of health. Many of the psychosocial variables clearly overlap, making it difficult to tease apart their individual contributions. Nevertheless, evidence of their collective role in healthy ageing is mounting, which importantly informs psychological interventions.

Debunking assumptions about ageing

This longitudinal research is enjoying the added bonus of exposing long held but inaccurate beliefs about ageing. Prof Luszcz says this is because the study is unique in tracking people at this stage in life for such a long time. "We are learning a lot about how people cope, and some of the assumptions that people have made for many years are turning out not to be true," she says. "Some of the results from cross-sectional studies are not substantiated when the same questions are examined longitudinally." One assumption that has been questioned is that cognitive functioning de-differentiates in old age, a concept that is central to developmental psychology. In the early years of life, cognitive abilities are generally de-differentiated, or coalesced, across areas of functioning and gradually become differentiated with age so that, for instance, some people become better at computing tasks, while others excel at reasoning tasks. It was thought that late in life de-differentiation reoccurs, but Prof Luszcz and colleagues have found no evidence for this. She says this finding relates to resilience in that it suggests people continue to maintain distinct cognitive functions later in life, just as they did earlier in life. "The maintenance of cognitive function is going to make you more resilient because you still have the capacity to solve problems, to invoke coping strategies and to see the value of social interaction." It also helps with accepting the ageing process. "You have to be able to be objective or rational about ageing and not let your emotions get the better of you in terms of regretting and ruminating over things that you can't change, and knowing when to accept things as you grow older." Prof Luszcz says this is hard to do and is an opportunity for psychologists to teach people the realities of ageing and the need to be sanguine about it.

Psychological interventions to promote resilience in ageing

Assisting older adults is an area ripe for the involvement of psychologists, who can also work on overturning common misperceptions that this age group cannot change, and that psychological problems are part of the normal ageing process. Dr Pachana at the University of Queensland says many people mistakenly think depression or anxiety is part of growing old. Research shows that, aside from dementia, the diagnosis of psychological disorders generally declines with age. However, subclinical levels of depression and anxiety are common, and treatable, she says. There is a small but growing number of robust empirical studies that provide strong evidence that older adults can benefit from psychological interventions for problems such as depression. Not obtaining treatment can be dangerous. For instance, depression may be a first symptom of a number of treatable disorders, including some cancers, but if this is explained away as ageing then early detection and treatment can be missed. Dr Pachana says memory problems may also hint at some physical problem that needs to be checked. "You just can't assume that because someone is over 65 a memory problem must be dementia because there are some things, such as metabolic disorders and medication interactions, which very commonly cause confusion and are relatively easily remedied," she says. "But if this person gets a label of being demented then they may never get the appropriate treatment."

Dr Pachana says it's important to be aware that effective treatment of older adults requires an age-appropriate adaptation of traditional therapies. "It's a myth that you can work with older adults in the same way that you work with adults," she says. Psychological treatments that have been found to be effective in assisting older adults have focussed on helping people rediscover coping skills and improve functioning. CBT-based interventions can promote a sense of control among older adults through education about their automatic thoughts and shifting their focus away from limitations and loss to concentrating on what they still have, and have achieved. CBT and forms of mindfulness or meditation can be beneficial because they don't require much physical energy and can be practised at home or in residential care. Regarding coping skills, Dr Pachana says that one of the most helpful things psychologists can do for people who are bereaved is to teach them a task that their spouse used to do, whether it's cooking or changing the car oil. "In many studies, teaching those kind of concrete skills has been shown to be more helpful than even talking about the death. Part of the reason they are not coping so well is because they are missing this big area of support, and if you teach them the skills then often the psychological coping improves."

Prof Luszcz at Flinders University adds that several of the psychosocial factors shown to be related to longevity are subject to change and improvement. In the case of social networks, interventions could be constructed that encourage forming more extensive social networks earlier in life, so that the benefits can continue to be reaped throughout the lifespan. "As with mental activity and efforts to promote physical health, it is important to be aware that we can positively influence our own ageing through interactions with people outside our immediate or extended family," she says. "Resilience is not purely an individual phenomenon. Social networks are known to be an effective buffer against life's stressors, as well as a source of emotional and practical support."

Unfortunately many older people don't seek psychological help and many healthcare providers are unaware of how to help older adults mentally. A lack of psychologists with training and experience in working with older adults is also hindering opportunities to help this age group. Prof Luszcz says there is a "crying need" to provide more opportunities for psychologists to train to work in geropsychology. The ageing sector is the most rapidly increasing part of the population, due partly to improvements in health, hygiene and technology over the years. She is also concerned about ageism in society and says there is a need to educate people of all ages about the realities of growing older. "But, as we begin to debunk the various myths about growing older and find that the vast majority of people in our sample are ageing well, ageism may decline."

References

Anstey, K J, & Luszcz, M A. (2002a). Mortality risk varies according to change in depressive status in a community sample of very old adults. Psychosomatic Medicine, 64, 880-888.

Anstey, K J, & Luszcz, M A. (2002b). Psychosocial factors, gender and late-life mortality. Ageing International, 27, 73-89.

Giles, L C, Glonek, G F V, Luszcz, M A, & Andrews, G R (in press). Social networks and 10-year survival in older Australians. Journal of Epidemiology and Community Health.

More information

The APS Psychology and Ageing Interest Group

Tips for working with older people in clinical settings

  • Take more time to introduce the client to psychotherapy because the current generation of older adults is likely to be unfamiliar with therapy. Seeing a psychologist may be perceived as a negative experience.
  • Teach skills more slowly than usual. For example, schedule extra sessions to teach skills such as relaxation.
  • Provide handouts of key concepts to facilitate information retention and homework. This is especially important when working with people who are memory impaired.
  • Check age-appropriate adaptations for specific therapies. For example, when teaching relaxation, visual imagery is more appropriate than progressive muscle relaxation because the latter may be painful for older adults who may have arthritis.
  • When working on coping skills, start with finding out what skills the client already has but has stopped practising. It is easier to reawaken existing skills than to teach new ones, which may not suit the client.
  • At the end of treatment, take more time to say goodbye because short-term relationships are rare experiences for older people whose relationships have typically lasted for decades.
  • Conduct the transition away from therapy with sensitivity and include a follow up, such as one month and three months after termination, to check that treatment gains are maintained.

Source: Dr Nancy Pachana, InPsych interview conducted January 2005

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