Chapter 13: Oldest-Old Elderhood (Ages 75 and Over)

INTRODUCTION TO THE OLDEST-OLD ELDERHOOD

• Conceptual Quote: Mark Twain famously stated, "Age is an issue of mind over matter. If you don't mind, it doesn't matter."

• Defining the Population: The "oldest-old," also referred to as the "very old," are individuals aged $75$ to $100$ years and older. This segment has grown rapidly since the turn of the $20^{th}$ century due to increases in longevity in Western countries and parts of Asia.

• Contextual Influences: Aging is influenced by sequential, environmental, and societal contexts (Wahl & Oswald, $2010$).

• History of Gerontological Counseling:

  • Blake & Kaplan ($1975$): Described older persons as "the forgotten and ignored" population of the counseling profession.

  • Myers & Blake ($1986$): Argued for specific training for counseling professionals to meet the unique needs of older adult clients.

  • Educational Imperative: Counselors must infuse gerontological issues into preparation courses and curricula to address this sector's rapid growth (Myers, $1995$).

UNDERSTANDING QUALITY OF LIFE AND LIFE SATISFACTION

• Multifaceted Definition of Aging: Birren ($1996$) identifies three distinct processes: (a) changes along the lifespan, (b) individual differences based on age and environment, and (c) the specific aging process of older adults compared to younger ones.

• The Continuous Balance: Lifespan involves a balance of stability, gains, and declines, particularly after the $3^{rd}$ decade of life (Baltes, $1987$).

  • Biophysical Systems: According to Briggs ($1990$), these systems typically lose efficiency.

  • Psychological Characteristics: These can maintain stability, show gains, or decline depending on the biological organism, sociocultural context, and individual behavioral control (Bandura, $1997$).

• Quality of Life (QOL) Meanings:

  1. Conditions for a Good Life: The presence of objective external factors deemed necessary for well-being.

  2. Practice of Good Living: The subjective practice of living well as an individual (Myers & Diener, $1996$).

• QOL Indicators and Definitions:

  • There are over $1,000$ identified indicators (Hughes & Hwang, $1996$).

  • There are over $100$ proposed definitions (Cummins, $1997$).

  • Core Components: Most definitions include a multidimensional functional status (physical, functional, emotional, and social well-being) and a subjectivity aspect (individual perception) (Muldoon et al., $1998$; Pukrop, $2003$).

• Perceptions of Vulnerability: The oldest-old are often seen as vulnerable due to: (a) declining capabilities, (b) disengagement from active life, (c) dependence on others for finance/support, (d) decrease in family networks, and (e) isolation due to deaths of spouses and peers.

LIFE SATISFACTION IN ADVANCED AGE

• Definition: Life satisfaction is an evaluative appraisal—both a state of mind and a degree of contentment. It refers to how much a person "likes the life he or she leads" (Myers & Diener, $1996$).

• Influencing Factors: Ability to function independently, pleasure in daily activities, perceived health, financial security, and social contact.

• Susceptibility to Threats: High risk of loss of spouse, relocation, comorbidity, and power deprivation from internal/external forces.

• The Health Narrative: Haber ($2019$) notes that health is more than the absence of illness; for the oldest-old, the inability to perform Activities of Daily Living (ADL) is the greatest concern to their QOL, often more than the presence of disease itself.

ADJUSTMENT TO ADVANCED AGING

• Operational Definition: How individuals perceive themselves regarding health concerns like chronic conditions, disability, and dependency.

• Physiological Reality: Epidemiology studies morbidity, mortality, and the causes of disability impacting independence. However, normal aging changes often have no impact on functioning unless the body is under stress (e.g., acute illness).

• Preventive and Corrective Proactivity (Kahana & Kahana, $1996; 2001$): Strategies to delay or minimize stressors:

  1. Health Promotion: Reducing the risk of declining health.

  2. Planning for the Future: Anticipating later-life needs.

  3. Helping Others: Enhancing social resources to be used during difficult times.

INTERPERSONAL RELATIONSHIPS AND SOCIAL CONNECTEDNESS

• Loneliness vs. Social Isolation: Psychological loneliness is distinct from an objective lack of connections and acts as a separate risk factor for poor health (Gironda & Lubben, $2002$).

• Connectedness Trends: While social network size often decreases with age, studies show age is positively related to neighborly socializing, religious participation, and volunteering (Hall & Havens, $2002$).

• The "Pruning Process": Research (Carstensen, $1992$; Lang, $2000$) suggests adults intentionally exclude peripheral relationships to retain emotionally close ones, which aids well-being in the oldest-old (Lansford et al., $1998$).

• Social Convoys: Kahn and Antonucci ($1980$) describe bands of people who accompany individuals through life; a core set of stable relationships predicts better functioning levels.

• Generativity: Feeling responsibility for the next generation. Nurturing intergenerational relationships helps oldest-old adults maintain a positive self-image (Vaillant, $2002$).

STRATEGIES FOR REDUCING ISOLATION AND LONELINESS

• Target Groups: Recommendations focus on older individuals, community groups/agencies, and policymakers (Adams et al., $2004$).

• Community Recommendations: Increase program availability, establish low-cost leisure activities, and involve seniors in planning.

• Policy Recommendations: Increase barrier-free access and housing that fosters socialization.

• Role of Counselors: Enhance communication links between social services, health, and education.

HELPING VULNERABLE OLDER ADULTS DURING CRISIS (COVID-19 CASE STUDY)

• The Impact of Social Distancing: Social isolation and loneliness were found to be twice as likely as obesity to be harmful to health. Lack of connection carries risks equivalent to smoking $15$ cigarettes per day or having a substance use disorder (Holt-Lunstad et al., $2015$).

• Suicide Risk: In studies of homebound older adults, $13\,\%$ exhibited serious suicide risk, with $2.4\,\%$ stating an attempt was "likely" (Van Orden et al., $2010$).

• Technological Barriers: While many use the internet, many lack skills for essential tasks like online banking or ordering food, leading to further isolation.

• Mental Health Disparities: Shortages of personal protective equipment (PPE), ICU beds, and ventilators during the $2020$ pandemic often led systems to prioritize younger patients over the vulnerable elderly.

• Religious Coping: Some adults use faith as consolation, expressing sentiments such as "I have faith in God, everything is going to be all right," requiring counselors to use these as foundations for support while presenting realistic options.

• FEMA Guidelines: Crisis counseling should engage people, encourage discussion of experiences, and teach stress management to promote resilience (FEMA, $2015$).

EMOTIONAL IMPACT OF CHRONIC ILLNESS AND RETIREMENT

• Adjustment Process: A long-term change in lifestyle, priorities, and self-image. Emotional wellness improvement can help control physical symptoms (Smyer & Qualls, $1999$).

• Retirement Transitions: Can lead to identity disruption, "postretirement void," and death anxiety. For those in management, loss of status can make them feel like "nobodies," whereas for those in tedious labor, it is a relief.

• Emotional Stability: Despite stereotypes of being sad/lonely, research shows adults reach high levels of affective well-being and emotional stability until ages $70$ or $80$ (Teachman, $2006$). Improvement to well-being is a general trend, not a guarantee.

• The Experience of Dependency: Older people fear dependency because they view themselves as a burden. Authentic relationships are established when caregivers accept the dependent person and allow them to function at their highest possible level.

PSYCHOSOCIAL CRISIS: EGO INTEGRITY VERSUS DESPAIR

• Erik Erikson’s Last Stage: The struggle between Ego Integrity (reflection on life with fulfillment and wisdom) and Despair (regret, bitterness, and fear of death).

• The Life Review: An empirical counseling intervention helping clients recall and reintegrate memories to find meaning in the life lived (Lewis, $2001$).

• Success vs. Failure:

  • Wisdom: The basic strength gained from a well-lived life.

  • Disdain: The core pathology, often reflecting self-contempt projected outward (Erikson, $1963$).

• Kübler-Ross Model (Five Stages of Grief): Applies to end-of-life and near-death experiences:

  1. Denial: Buffers the initial shock/reality of terminal illness.

  2. Anger: Directed at God, the self, or others (e.g., "Why me?").

  3. Bargaining: Attempting to postpone death by making promises to a higher power.

  4. Depression: Reactive (loss of function) or preparatory (separation from life).

  5. Acceptance: A sense of peace and relative tranquility.

END-OF-LIFE PLANNING AND PRINCIPLES

• Statistical Context: CDC reports show the mortality rate for persons aged $65$ and over was $2,067,404$ in $2017$.

• Core Principles for Care (Table $13.2$):

  • Respect the dignity of patients and caregivers.

  • Alleviate pain and address spiritual/social problems.

  • Assure access to palliative and hospice care.

  • Respect the right to refuse treatment.

CASE ILLUSTRATIONS

• Case $13.1$ (Adjustment): John ($75$), White, refuses medications and insists on unsuitable physical chores, resulting in a bad mood and loss of temper. Questions include: Is this dependency or fear of aging?

• Case $13.2$ (Ego Integrity): Karl ($78$), Black, lives in a senior complex, stays home, and complains constantly, causing family to avoid visits. Questions include: How can counseling assist Karl in finding worth?

• Case $13.3$ (End-of-Life Planning): Nelly ($75$), Black, moved from the South to the Northeast at $16$. She wishes to move back to the rural South against her daughters' advice to die where she was born. Questions include: Is this a psychosocial crisis influenced by culture?

GERONTOLOGICAL COUNSELING EXPERTISE

• CACREP Standards: The $2016$ manual emphasizes high-level skills beyond generalist counseling for gerontological specialties.

• Altekruse & Ray ($1990$) Recommendations:

  • Demonstrate competence and be cautious with psychological testing.

  • Attend to the physical environment more than with younger clients.

  • Act actively as a client advocate.

  • Focus on short-term goals and the present life.

• Wellness Philosophy: Myers ($2003$) emphasizes "Wellness in Later Life," moving away from purely reactive/curative attitudes toward active aging for Baby Boomers.

• Essential Competencies: Knowledge of elder abuse, substance misuse, organic brain syndrome, art and pet therapies, and ethical issues specific to advanced age.

CULTURAL COMPETENCE

• Barrier Realities: Culture is a common barrier for minority and immigrant clients. For example, Hispanic immigrants may avoid centers without Spanish-speaking staff.

• Health Inequities: Minority older adults face higher rates of disability and death and lower service quality.

• Professional Strategies:

  • Recruit ethnically and racially diverse workforce.

  • Ensure language assistance for those with limited English proficiency.

  • Encourage sensitivity to historical, tradition-based value systems.

FUTURE PROJECTIONS

• Population Growth: US older population is projected to reach $88.5$ million by $2050$ (doubling the $40.2$ million in $2010$).

• Sustainability: The oldest-old constitute the fastest-growing proportion of Western societies and will require substantial societal support systems.