Psychosocial Aspects of Human Aging, & Successful Aging

1. Psychosocial Aspects of Human Aging, & Successful Aging Gail M. Sullivan, MD, MPH UConn Center on Aging

2. Demography ≥ 65 years: • 50% of MD visits • 33% of prescribed meds • 90% of long term care beds • 60% hospital bed days vs. 13% of population – % increasing to 20% by 2030

3. Baseline Data • Family Circumstances • 80% elders living alone have close contact w/ a child • Living Arrangements • 41% women live alone vs. 15% men • 2/3+ of nursing home beds occupied by women • Marital Status- more women are widows • Economic Status • Poverty rates decreased with Social Security

4. What is Normal Aging? • “Successful” • Usual or customary • Diseases associated with aging

5. Example 1 • Essentially no change in creatinine clearance (2 S.D. better than mean) • Moderate slow decline - use formula to predict (140-age) X body wt. (kg) (X .85 ♀) 72 X serum creatinine • Renovascular disease, HTN So what? Important in drug dosing

6. Creatinine Clearance Age, Yrs. Creatinine

7. Example 2 • No memory decline (with or w/out training) • Slowed information retrieval, slower reaction times • Alzheimer’s dementia, vascular dementia So what? “Senile” dementia does not exist

8. Example 3 • Preserved skeletal muscle (older athlete) • Decreased skeletal muscle, increased % fat • Sarcopenia with cardiac, renal diseases So what? Drug dosing; exercise may reverse declines in strength

9. Example 4 • Height preserved, normal BMD Bone Mineral Density • Gradual loss of height (1-2 inches), osteopenia • Osteoporosis, fractures So what? Osteoporosis preventable, treatable, often undetected, not normal

10. Conclusion: Normal Aging We know: - a lot about customary aging - greater understanding of diseases associated with aging - beginning to understand the prescription for “successful aging”

11. Ageism • Prejudice for or against likelihood of a condition, or any assumption based solely on a patient’s age • Example: 88 y/o with decreased walking • Patient, family & health professionals all have ageist stereotypes

12. “Who’d you draw in the jousting tournament?” “How’d he get to be 97?”

13. Tom Lackey, 89, took up wing-walking as a way past the grief of losing his wife. Here, he is flying across the English Channel.

14. Ilse Telesmanich, 90, hiking in South Africa

15. Stereotypes • Wrinkled, leathery skin • Fragile bones • Sexless • Physically weak • Blind • Deaf • Memory impaired • Sick

16. Reality • Tremendous heterogeneity

18. Functional Assessment • AADL • Driving • Leisure activities, travel • IADL • Managing finances – Cooking • Arranging transportation – Cleaning, laundry • Managing meds – Telephone • Shopping • ADL • Bathing – Ambulation, stairs • Personal hygiene – Transferring OOB, chair • Toileting, continence – Feeding

19. Mr. A Cardiac disease with congestive heart failure Mrs. A Asthma Mild hearing loss Osteoarthritis Constipation Osteoporosis Uterine Fibroids Hip Replacement Cholecystectomy Non-critical AS Diverticulosis, itis Hypertension Actinic keratoses Diabetes mellitus Urge incontinence Cataracts Diseases

20. Mrs. A Independent in AADL, IADL, ADL Able to travel, play bridge, drive, manage finances, shop, cook, manage meds for both, bathe, dress, walk, transfer, toilet, & eat Function Status • Mr. A • Dependent in AADL, IADL, & ADL • Except for feeding & personal hygiene

21. Functional Loss in Older Persons • Final common pathway for disease • First presentation of disease • Primary determinant of quality of life • Function may be more important than diagnosis

22. Social Factors - Demographic • Age - functional loss usually due to chronic disease, but lost function may be recovered • Gender- women live longer, but have worse functional status, due to • Osteoporosis, osteoarthritis, sarcopenia, dementia • Heart disease, cancer, CVA • Race - minority status • Worse health, function, survival • Reasons: behaviors, environment, access to health care, but socioeconomic status (SES) most important • If control for SES, race not an independent RF, when aged • 2 most important factorsfor mortality/dysfunction in late life: • SES & smoking - & smoking prevalence is related to SES

24. Social Factors & Mortality • Multiple studies show association – but how? • Caring network encourages healthful practices • Caring network improves adherence to treatments • Groups or individuals provide actual physical or financial help • Effects on immune function • Effects on neuro endocrine function • Social integration (attachments to groups) & social support (attachments to people) • Attendance at church assoc. with better function • Participation in voluntary groups assoc. with ↓ mortality • Social supports associated with improved health outcomes, e.g., better recovery from MI, CVA • Intervention studies: ↑ self-efficacy (= personal capacity to effect change & control events, i.e. promote ‘can do’) • Maintain sense of well-being, able to adapt to stressors (disease, disability, spouse illness or death, moves) • Live longer • Better health status, better cognitive status

25. Studies RATS • Social isolation suppresses wound healing and immune response • Timid rats w/ less drive to explore die 6 months earlier than siblings who explore HUMANS • Morbidity assoc. with social isolation equal to that of cigarette smoking

26. Social Factors- Birth Cohorts • Each successive 5 yr cohort: • More education • More money • Better health • Effects of better environment, nutrition, prevention • Also due to higher SES • Taller

27. Transitions • Aging brings losses • Spouse, friends, children • Job, income, status • Home, neighborhood • Health, function • But coping skills improve with age

28. Transitions: Retirement • Gender roles- stereotypic, but may be relevant to current retirees • Men- defined by work and income • Status, identity, social role, friendships are work-dependent; retirement terminates all • Increased mortality if widowed • Women- use outside-of-work activities for all but income • Retired women less likely to be “at a loss”

29. Transitions: Widowhood Grief versus depression • Grief - appropriate response to death • Sadness, depressed feelings, crying, loss of interest in usual activities • Abates in 4-8 weeks; sadness & crying persist 6-12 mo. • Encourage talking, association with friends, family • Norms are culturally-dependent • Grief > 3 mo. + symptoms of major depression - may be depression

30. Transitions: Relocation Relocation effects determined by: • Voluntariness • Nature of new living arrangement: independent, assisted living, nursing home • Predicted, controlled vs. not (determines stress) • Physical & cognitive function

31. Transitions: Chronic Disease & Disability Chronic disease & disability • Increase with age • But - opportunities to delay and ameliorate losses • NIH study of older disabled women - still have active, involved lives, important social roles • Disability does not equal poor quality of life or depression

32. Coping Mechanisms (1) Coping - adaptive responses to stress which reduce harm to psychological well-being • Specific coping styles: anger, guilt, denial, accommodation, problem-solving, social involvement • More mature and successful techniques (accommodation, problem-solving, social involvement) - more common with age

33. Coping Mechanisms (2) • Comparisons with peers (rather than to past self) • How well am I doing vs. my friends • Are events expected milestones • Shifts in centrality • What roles are central to my identity? shift from: • Breadwinner to volunteer • Parent to grandparent • Head of household to sage dispensing wisdom • Ability to transition to another role is vital to well-being

34. Psychological Processes • Processes in healthy older adults, relevant to care • Attention – maintain performance on a task over time; focus without losing track • Sustained attention very good in healthy older adults • Easier distractibility with age, esp. when irrelevant information presented with relevant • So what? When giving key info, stick to core data, write it down Decreased attention requires eval., as it is not normal

35. Learning & Memory • 14 - year longitudinal study, 70 + year-olds • < half had small declines in long term memory • 5 brief training sessions improved decline to baseline • Majority, with no decline, improved after training • Apparently ‘age-obligatory’ losses are modifiable Use it or lose it? • So what? Encourage encoding strategies, refer to reputable memory training, write down instructions or recommendations

36. Cognitive Training & Function • Large RCT, community elders, av. age 74, 4 groups • 10 sessions memory training (verbal) • 10 sessions reasoning training (inductive) • 10 sessions speed of processing (visual search & ID) • Controls • All training groups showed improvement in area trained; this persisted 5 yrs later • Reasoning group: less difficulty in IADL vs. controls at 5 yrs • Subgroup with ‘booster’ training at 11 & 35 mos. • Had additional improvement in targeted area • Conclusion: cognitive training improves specific areas trained & reasoning training results in less functional decline

37. Language • Vocabulary - increases into 50s & 60s; occasional errors in naming occur more frequently beginning in mid-life; use encoding strategies • Syntactic skills - combine words in meaningful sequence - no change with age • So what? Write names down; other changes in language require evaluation

38. Cognitive Function: Bottom Line • Normal aging does not cause cognitive loss • Diseases • Dementia, delirium, depression • vs. incorrect assessment or diagnosis • Deafness, aphasia, language barrier • Usual change: increase in reaction time, which is modifiable with training So what?Don’t diagnose “senile dementia” or “chronic OBS”

39. Sensory & Perceptual Processes:Vision • Declines with age • Acuity, color & brightness discrimination decline • Light sensitivity increases (glare) • Visual processing speed (reading) declines - ? Modifiable • Dynamic vision (scrolling messages on TV screen) declines • Depth perception, figure-ground discrimination, visual search (important for driving, e.g., locating a sign) decline • Clinical points: bright, non-glare light; large, high contrast print; annual OPTOMETRY eval

40. Hearing • Losses prevalent & >50% are clinically important • Presbycusis is common – progressive, bilateral, mixed sensorineural & central processing loss of hearing • Exacerbated by acoustical trauma • High tones lost: consonants most difficult to hear • Clinical points: screen all, enunciate, don’t shout, low pitch best

41. Conclusions • Population aging rapidly & elders use more health services & products • Enormous heterogeneity in elders – in function, diseases, & coping strategies • Certain diseases associated with aging but not part of usual aging • Most elders independent & live in the community, despite chronic diseases • Social factors have powerful effects upon function, recovery & mortality (poverty & smoking in mid-life are the worst) • “Positive” attitude towards aging assoc. with longevity; interventions to boost self-efficacy show better outcomes • Cohort effects may be important: WWII elders vs. baby boomers • Important neuropsychol. changes: hearing & vision decline; reaction time declines • Insignificant or no changes: attention, learning, memory, language • Function is primary determinate of quality of life for elders