ADULTHOOD AND OLD AGE DEATH AND DYING

Young Adult: __ to _ years of age

20-40

Young Adult- Characterized by:

• Peaking biological development

• Assumption of major social roles and establishing an identity congruent with new roles

• Evolution of adult self and life structure

Young Adult - Successful transition required satisfactory __________________

resolution of childhood and adolescent crises

TRANSITION FROM ADOLESCENCE TO YOUNG ADULTHOOD - Characterized by:

real and intrapsychic separation from the family of origin and engagement of new, phase-specific tasks

Development Tasks of young adulthood

1. To develop a young adult sense of self

2. To develop adult friendships

3. To develop the capacity for intimacy, to become a spouse

4. To become a biological and psychological parent

5. To develop a relationship of mutuality and equality with parents when facilitating their midlife development

   • Not everything is dictated to you by parents

6. To establish an adult work identity

7. To integrate new attitudes towards time

Young Adult - Work Identity

→ SOURCE OF FRUSTRATION VS ENHANCE SELF-ESTEEM

• Blue collar jobs → out of HS or elementary to work agad

• White collar jobs → college then go into chosen eld

• Looking if you get recognition

UNEMPLOYMENT → Can damage one's core identity

• Feelings of worthlessness

• Other people will view you as walang kwenta, walang pangarap

Young Adult - Developing Adult Friendships

• Primary source of emotional sustenance

• Substitute siblings and parents until more permanent replacements are found (own spouse, children)

Young Adult - Sexuality and Marriage

• Search for intimacy

• Increases desire for marriage

Young Adult - Parenthood

• Increases bond between new parents

• Expands their internal image of each other to include thoughts and feelings emanating from the role of a parent

• Continuing process of letting go

  • Separation from children and enhancing their independence

Golden age of adulthood

Middle Adulthood

Middle Adulthood - __ to _ y/o

40-65 y/o

Where midlife crisis happens

Middle Adulthood

Middle Adulthood - Work

• Some experience gap between earlier aspirations and current achievements

Development Tasks in Middle Adulthood - Men

May develop qualities that enable them to express emotions and recognize their dependency needs, traits that are considered feminine

Development Tasks in Middle Adulthood - Women

• No longer need to nurture young children

• Release the energy into independent pursuits

• Competitive and assertive

• Considered masculine

Robert Butler - Issues in Middle Adulthood

1. Prime of Life

2. Stock taking: what to do with the rest of one’s life

3. Fidelity and commitments

4. Growth-death; Juvenescence and rejuvenation fantasies

5. Communication and socialization

Prime of Life - Positive Features

• responsible use of power

• maturity

• productivity

Prime of Life - negative features

• winner-lose view

• competitiveness

Stock taking - Positive Features

what to do with the rest of one’s life

• Possibility

• alternatives

• organization of commitments

• redirection

Stock-taking - Negative Features

• closure

• fatalism

Fidelity and commitments - Positive Features

• commitment to self, others, society

• filial maturity

Fidelity and commitments - Negative Features

• Hypocrisy

• Self-deception

Growth-death - Positive Features

Naturality regarding body, time

Growth-death - Negative Features

• Obscene or frenetic efforts (e.g., to be youthful)

• Hostility and envy of youth and progeny

• Longing

Communication and socialization - Positive Features

• Matters understood

• Continuity

• Picking up where left off

• Large social network

• Rootedness of relationships, places, and ideas

Communication and socialization - Negative Features

• Repetitiveness

• Boredom

• Impatience

• Isolation

• Conservation

• Confusion

• Rigidity

Erik Erikson - Generativity vs Stagnation

Generativity	Stagnation
Process by which persons guide the oncoming generation or improve society Raising children (wanting and having children does not ensure generativity) No children: Helping others Being creative Contribute to society	Stops developing Being in a cocoon of self-concern and isolation

Middle Adulthood - Developing Midlife Friendships

• Usually do not have sense of urgency or the need to be frequently or nearly in constant physical presence of friend

• Constant sources of gratication through: spouse, children and colleagues

• Reappraising relationships – settle for what they have or search for greater perfection (affair, trial separations, divorce)

  • Providing a safe place for conict and difference = acceptance

  • Holding a double vision of each other (Understanding that spouse is not perfect)

  • Maintaining a healthy sexual life

Middle Adulthood - Sexuality

• Focused on maintaining intimacy in the face of pressures

• Diminished sexual ability is compensated by feeling of love and tenderness generated over the years by a satisfying relationship

• Acceptance of partner’s middle-aged body, find it stimulating and accept normative changes in sexual function

Middle Adulthood - Climacterium

• Decreased biological and physiological functioning

Men	Women
Andropause Mid-Life Crisis	Menopause
Sudden drastic change in work or marital relationships, severe depression, increased drug or alcohol use and shift to an alternate lifestyle Accompanied by significant, ongoing emotional turmoil for the individual and others

Middle Adulthood - Empty Nest Syndrome

• A depression that occurs in some when the youngest child is about to leave home

• More common in the US

• Most predominant in females

  • Especially those whose predominant role in life is motherhood and those that stay in unhappy marriage “for the sake of children”

• Develop compensating activities

Middle Adulthood - Adult Maturity

• Achieve of maturity — a mental state, NOT age

• Mental state found in healthy adults

• Characterized by detailed knowledge of parameters of human existence, a sophisticated level of self-awareness based on honest appraisal of one’s own experience and the ability to use this intellectual and emotional knowledge and insight caringly in relation to one’s self and others

• Emergence of Wisdom

Late Adulthood - _ age

65 years of Age

Young Old

65-75

Old-Old

75 and beyond

Late Adulthood - Shift from ______ to _________

pursuit of wealth to maintenance of health

Central Concern: aging body

Development Tasks of Late Adulthood

• To maintain the body image and physical integrity

• To conduct the life review

• To maintain sexual interests and activities

• To deal with the death of signicant loved ones

• To accept the implications of retiremen

• To accept the genetically programmed failure of organ systems

• To divest oneself of the attachment to possessions

• To accept changes in the relationship with grandchildren

“Increasing control of the ego and id with aging results in increased autonomy. Regression may permit primitive modes of functioning to reappear”

OLD AGE DEVELOPMENTAL THEORISTS - Sigmund Freud

• “Central conict in old age is between:

  • INTEGRITY

  • DESPAIR

• Contentment in old age comes only with getting beyond narcissism and into intimacy and generativity.”

OLD AGE DEVELOPMENTAL THEORISTS - Erik Erikson

the sense of satisfaction people feel reflecting on a life lived productive

Integrity

the sense that life has little purpose or meaning

Despair

• “Old people must continually cope with narcissistic injury as they attempt to adapt to the biological, psychological, and social losses associated with aging process

• The maintenance of self-esteem is a major task of old age.”

OLD AGE DEVELOPMENTAL THEORISTS - Heinz Kohut

“The major conflict of old age relates to giving up the position of authority and evaluating achievements and former competence. It is a time of reconciliation with others and resolution of grief over death of others and approaching death of self.”

OLD AGE DEVELOPMENTAL THEORISTS - Bernice Neugarten

“Age 60-65 is a transition period. People who are narcissistic and too heavily invested in body appearance are liable to become preoccupied with death. Creative mental activity is a normal and healthy substitute for reduced physical activity.”

OLD AGE DEVELOPMENTAL THEORISTS - Daniel Levinson

Psychosocial Aspects of Aging

1. Social Activity

2. Ageism

Psychosocial Aspects of Aging - Social Activity

• Healthy older persons usually maintain a level of social activity that is only slightly changed from that of earlier years

• Continued intellectual, emotional and psychological growth

• CONTACT WITH YOUNGER PERSONS → pass on cultural values and provide care services to the younger generation and thereby maintaining a sense of usefulness that contributes to self-esteem

• Isolated → can become depressed

• Contact with younger person→ self-esteem

Psychosocial Aspects of Aging - Ageism

• Refers to discrimination toward old persons and to the negative stereotypes about old age

• Loneliness, poor health, senility, and general weakness

Psychological Problems of Older Persons

• Prevalence of major depression and dysthymia is actually LESS than in younger age groups

• Depression often accompanied by physical symptoms or cognitive changes that may mimic dementia

• HIGH incidence of suicide (40/100,000)

• Dementia

• Psychotic disorders

End of Life Issues

1. Death

2. Dying

End of Life Issues - Death

• Absolute Cessation of vital functions

Good Death	Bad Death
One that is free from avoidable distress and suffering for patients, families, and caregivers Is reasonably consistent with clinical, cultural, and ethical standards	Needless suffering A dishonoring of the patient or family’s wishes or values A sense among participants or observers that norms of decency have been offended

Process of losing vital functions

Dying

Stages of Death and Dying

1. Shock and Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

Stages of Death and Dying - Shock and Denial

• Feelings of isolation

• May search for another health care professional who will give a more favorable opinion

• May seek unproven therapies

• Denial can be an adaptive response, providing a buffer after bad news.

• It allows time to mobilize defenses but can be maladaptive when it prevents the patient or the family from seeking help or when denial behaviors cause more pain or distress than the illness or interfere with everyday functions.

• Nurses should assess the patient’s and family’s coping style, information needs, and understanding of the illness and treatment to establish a basis for empathetic listening, education, and emotional support

• Rather than confronting the pt with information that he or she is not ready to hear, the nurse can encourage him or her to share fears and concerns

Stages of Death and Dying - Anger

• “Why me?”

• Feelings of rage, resentment, or envy directed at God, health care professionals, family, others

• Anger can be very isolating, and loved ones or clinicians may withdraw

• Nurses should allow the patient and family to express anger, treating them with understanding, respect, and knowledge that the root of the anger is grief over impending loss

Stages of Death and Dying - Bargaining

• “I just want to see my grandchild’s birth, then I’ll be ready..”

• Patient and/or family plead for more time to reach an important goal

• Promises are sometimes made with God

• Terminally ill pts are sometimes able to outlive prognosis and achieve some future goal

• Nurses should be patient, allow expression of feelings, and support realistic and positive hope

Stages of Death and Dying - Depression

• “I just don’t know how my kids are going to get along after I’m gone.”

• Sadness, grief, mourning for impending losses

• Normal and adaptive respons

• Clinical depression should be assessed and treated when present

• Nurses should encourage the pt and the family to fully express their sadness

• Insincere reassurance or encouragement of unrealistic hopes should be avoided

Stages of Death and Dying - Acceptance

• Patient and/or family are neither angry nor depressed

• The pt may withdraw as their inner circle of interest diminishes

• The family may feel rejected by the pt

• Nurses need to support the family’s expression of emotions and encourage them to continue to be present for the pt

Subjective feeling precipitated by death of a loved one

grief

Process by which grief is resolved

Mourning

Bereavement

• State of being deprived of someone by death

• State of mourning

NORMAL BEREAVEMENT REACTIONS

Protest → Searching → Loss of hope to reestablish attachment → Despair → Detachment → Reorganization

Anticipatory Grief

• Grief reactions brought on by slow dying process of a loved one through injury, illness, or high-risk activity

• Soften the blow of eventual death

• Can lead to premature separation and withdrawal while not necessarily mitigating later bereavement

Bereavement vs MDD

Bereavement	Major Depressive Disorder
Symptoms may meet syndromal criteria for major depressive episode, BUT the survivor rarely has morbid feelings of guilt and worthlessness, suicidal ideation, or psychomotor retardation	Any symptoms as defi ned by DSM
Considers self bereaved	May consider self weak, defective, or bad
Dysphoria often triggered by thoughts or reminders of the deceased	DYSPHORIA often becomes chronic, intermittent, or episodic
ONSET is within the first 2 mo of bereavement	ONSET at anytime
DURATION of depressive symptoms is less than 2 mos	Depression often becomes chronic, intermittent, or episodic
Functional impairment is transient and mild	Clinically significant distress or impairment
No family or personal history of major depression	Family or personal history of major depression

Palliative Care

• Refers to providing relief from suffering caused by pain or other symptoms of terminal disease

• Shift from active curative to palliative care

• Most important task of a physician: determine the time for curative care has ceased and only then the palliative care can begin

  • Communication, telling the truth, respect, empathy

• Psychological symptoms are nearly universal at the end of life

  • Anxiety, depression, and confusional states

Endicott Substitution Criteria for Depression - Physical / Somatic Symptoms

• Changes in appetite or weight, or both

• Sleep disturbance

• Fatigue, loss of energy

• Memory and concentration deficits, indecisiveness

Endicott Substitution Criteria for Depression - Psychological Symptom

• Tearfulness, depressed appearance

• Social withdrawal, deceased talkativeness

• Brooding, self-pity, pessimism

• Lack of reactivity

Advance Directives

• Wishes and choices about medical interventions when the patient’s condition is considered terminal

• 3 types:

  1. living will

  2. health care proxy

  3. DNR and DNI orders

Advance Directives - Living Will

Mentally competent patient gives specific instructions that doctors must follow

Advance Directives - Health Care Proxy

• Durable power of attorney

• Gives another person (surrogate) the power to make medical decisions when the pt is unable to

• BASIS: what he or she thinks the pt would want

Advance Directives - DNR & DNI

Do Not Resuscitate; Do Not Intubate

Common End-of-Life Symptoms / Signs

1. Cachexia

2. Delusions

3. Delirium or Confusion

4. Depression or Anxiety

5. Dysphagia

6. Dyspnea or Cough

7. Fatigue

8. Incontinence

9. Nausea or vomiting

10. Loss of Skin Integrity

11. Pain

Common End-of-Life Symptoms / Signs - Cachexia

Comments	Management / Care
All terminal disease states are associated with cachexia secondary to anorexia and dehydration	Feeding tubes useful in some cases Small sips of water of help

Common End-of-Life Symptoms / Signs - Delusions

Comments	Management / Care
Common in terminal state	Antipsychotic medication useful

Common End-of-Life Symptoms / Signs - Delirium or Confusion

Comments	Management / Care
Occurs in nearly 90% of all terminal pts but is reversible in over 50%	Can be reversed if cause is found and treatable May respond to antipsychotic and/or pain medication

Common End-of-Life Symptoms / Signs - Depression or Anxiety

Comments	Management / Care
Psychological factors, e.g., fear of death, abandonment and/or physiological factors, e.g., pain, hypoxia	Antianxiety and antidepressant medication of use Opioids have strong antianxiety effects

Common End-of-Life Symptoms / Signs - Dysphagia

Comments	Management / Care
Seen in neurological disease, e.g., multiple sclerosis, amyotrophic lateral sclerosis	Attention to oral care e.g. ice chips, lip balm Adjust to upright position when feeding

Common End-of-Life Symptoms / Signs - Dyspnea or Cough

Comments	Management / Care
Associated with severe anxiety; fear of suffocation in extreme case; common in lung cancer pts	Opioids, supplemental oxygen, bronchodilators of use

Common End-of-Life Symptoms / Signs - Fatigue

Comments	Management / Care
Most common occurrence in terminal illness	Psychostimulants can be used for relief

Common End-of-Life Symptoms / Signs - Incontinence

Comments	Management / Care
Associated with radiation-induced fistulas	Keep pt clean and dry Use indwelling or condom catheter if necessary

Common End-of-Life Symptoms / Signs - Nausea or Vomiting

Comments	Management / Care
Side effect of radiation and chemotherapy	Antiemetics, e.g., metoclopramide, prochlorperazine Marijuana of use

Common End-of-Life Symptoms / Signs - Loss of Skin Integrity

Comments	Management / Care
Decubiti most common on WB areas	Turn body frequently Elbow and hip pads Inflating mattresses

Common End-of-Life Symptoms / Signs - Pain

Comments	Management / Care
Pain medications can be administered orally, sublingually, by injection or infusion, or via skin patch	Opioids are the gold standard