Students’ Questions

This photo was taken by our artist-friend Barb Pennypacker in Italy

Our friend Karen Fingerman asked students in her class on adult development and aging at the University of Texas—Austin to look at our blog, and ask us questions that they would like us to answer.  Her teaching assistant, Jacqueline DeAnda, selected 7 questions and sent them to us.  Here are the questions and our answers. 

Two questions on death and dying --Answered by Judy

Question 1:  How do you feel about death, and has that changed over time? How do you learn to stop fearing death and accepting it as a reality of life?

Right now, as a fairly healthy 72-year old, I see death as something that inevitably will occur in the next ten to fifteen years.  In part that is because that is what was true for my parents and grandparents, but I also know it to be statistically true. In the past few years, my perspective has changed, as the years ahead have shrunk and the years behind have grown.  Before, if I thought about death in relation to myself, I wanted to live long enough to see my children grown and well-established in their lives.  Once that was achieved, I wanted to live long enough to enjoy our grandchildren, and we are living that life right now. Because grandchildren came relatively late in our lives, (I was 62 and Steve was 63 when our first grandson came to us), we cannot count on seeing great-children, so our hopes are to see most of them graduate from high school, maybe some from college. 

During my clinical practice I worked with many elderly individuals, and I followed them from my outpatient practice to assisted living, to skilled nursing, and in some cases was present at their death.  As their psychologist, they confided their inner-most thoughts about aging and death to me, and I learned a great deal from them.  I can say that most of my clients did not fear death itself, they had long ago come to terms with that.  In fact, if you live to be 75 or 80 you have inevitably lost many people along the way.  But they did fear how they would die.  Most people will say that they hope they will just go to sleep one night and not wake up in the morning.  Not many people have exactly that experience, but I came to understand that because prior to dying, consciousness diminishes (either suddenly or gradually), the experience of death may indeed feel like this.  

What I can say from my own personal experience and my observations of my clients, is that the experience of aging is a combination of the body very gradually becoming less efficient and the accumulation of physical limitations brought on by injury or illness.  Thus, by the time you are 70, you can expect to slow down somewhat, to have some everyday aches and pains, and to take longer to recover from over-exertion.  As this process goes on, I think we gradually accept the idea that there will be a natural end point, even if we can’t completely grasp what that will mean.

When I was young, I rarely thought about death, certainly not in relation to myself.  As the years have gone by, I have moved from a position of bargaining (“Just let me live long enough to see my children launched”) to a position of curiosity. Now if I think about death in relation to myself, I wonder about the when and the how, but I am really curious to know what that experience will be.  I do make a point of letting my family know my wishes on my end of life, to control the things that I can, but, in the end, death will come when it is my time, and I hope I will greet it familiarly, something like, “Oh, it’s you after all these years.”

Question 2:  When an old-age person finds themselves incapacitated, in a coma and on life support, what is a sufficient length of time for the family to leave them on life support to see if they will recover before pulling them off life support?

There really isn’t a rule of thumb about how long to wait to see if someone who is on life support will recover, as circumstances vary tremendously. However, there are several important factors to consider.  It is important to listen to what the medical team is telling you about the chances of recovery, and what would that recovery look like.  Based on their tests, will the person ever be able to regain consciousness, breathe independently, or be able to perform any activities of daily living for themselves?  What would the quality of life be likely to be?  Does the family know the wishes of the patient?  

If the person has advanced directives, they should address this very situation.  If there are no advanced directives, but there are one or more family members who know what the patient’s thinking was, they should convey those wishes to the medical team.  My experience is that the medical teams that work in hospitals and skilled nursing homes are in the best position to give you a realistic idea of what will happen when life support is withdrawn.  

The next question is about caregiving stress and its effects

3.  What are the physical effects of taking care of a spouse with dementia or Alzheimer’s disease? Does it shorten life expectancy or potentially cause a late onset of mental illness?

Chronic stress takes a toll on physical and emotional health.  When we encounter a stressor in our daily life, we have a physiological response that prepares us to respond to threat.  This is the well-known “fight or flight” reaction.  Heart rate increases, our hands sweat, our attention is focused. Hormones such as adrenaline and cortisol fuel this process.  In the short run, the physiological changes with stress do not result in any harm, but repeated exposure to stressors over time can lead to dysregulation of these hormones—either too much or too little of a hormone.  These changes, in turn, affect our cardiovascular and immune systems and make us more vulnerable to illness and to emotional distress.  And chronic stress may increase risk of dying.

Given the effects of chronic stress, it is not surprising that caregivers of persons with dementia have more health problems and greater emotional distress than people of the same age who are not caregivers.  Caring for someone with dementia is one of the most stressful activities we encounter. People with dementia need ongoing care and supervision so that they do not harm themselves or someone else. They may become agitated and restless and caregivers can have difficulty calming them down.  They may mix up day and night and keep caregivers awake at night. Caregivers feel like they are always on call and must be vigilant all the time.  The most popular book about caregiving is aptly titled, The 36-Hour Day.

It is also important to recognize that there are factors that mitigate the harmful effects of stressors.  My research team has shown that caregivers who use adult day care have improved regulation of key hormones and reduced emotional distress on days their relative attends an adult day program.  Other research shows that caregivers who engage in enjoyable activities show less distress and lower levels of markers of risk for cardiovascular disease and stroke.  Caregivers also may lower stress by placing their relative into a care facility, although they may encounter new stressors associated with placement.

Finally, we want to emphasize there are considerable individual differences in how caregivers react to stressors.  Some people have good coping responses or find ways to get regular breaks from providing care.  Helping more caregivers to cope in more effective ways with predictable stressors and to access services such as adult day care may be able to reduce the health and emotional problems they experience.

Next, we turn to two questions on perceptions of old age -- Answered by Steve

4.     Is there a common age range when people begin to perceive themselves as “older people”?  If so, has this age range changed throughout the past century and what could have accounted for the change in this age threshold?

5.     With all of the experience and knowledge of old age shared between the two of you, at what age do you consider someone old?

The stock answer is to say that someone who is 10 years older than you is “old”. 

The serious answer is that your perception of age depends on health, functioning and appearance.  Most mornings Judy and I go to the gym and work out for about 45-50 minutes.  We feel good afterwards.  Of course, there are things we cannot do that we did 30 or 40 years ago, but most days we don’t say, “I feel like 72 today.”  We are chronologically old, but the term “feeling old” refers to frailty and illness.  In that sense, we are fortunately not old.  

When researchers have examined subjective age, they typically found that people compare themselves to others they know who are about the same age.  If they see that they are doing better in terms of health and everyday functioning compared to their friends or relatives, they report feeling younger than they are.  Going to the gym has been very helpful to our own perceptions of age.  We look around and think we are not doing badly at all.

For people whose physical appearance is a key part of their self-esteem, old age is harder.  Standards of attractiveness are based on features of young adults.  This is particularly the case for women.  More positive images of older people in the media are helping with this issue.

Whether the age range where people see themselves as “older” has changed is a really good question.  I don’t know if there is definitive information to answer this question.  As you know, more people live to 65 and older than ever before, as well to 75, 85 and beyond.  And on average they are in better health than in the past.  So while the social definition of “older” is 65, it’s likely that people don’t perceive themselves as old at 65 or even 75.  

What age do we consider “old?”  After 80 and particularly after 85, nearly everyone has one or more chronic illness and physical limitations become more common, not to mention dementia. In research I conducted with colleagues in Sweden, we found that decline in health and functioning accelerated after 85.  But our research also showed that there were some “successful agers” at every age who were doing quite well.  The proportion of these successful agers, however, declines with advancing age.

Then there is the perspective of our 6-year-old grandson who told a friend of his, “My grandparents are really old.”

We end with two questions concerning the negative stigma associated with old age --answered by Steve

6.     What are some ways we can get rid of negative stigmas about older people in a society where aging is constantly associated with physical and mental decline?

7.     How did you manage to self-actualize your own lifestyle choices and habits after breaking apart the stereotype of ageism?

Negative stereotypes, whether about race, ethnicity, gender, age or anything else, can have harmful effects.  Some of the efforts to combat age stereotypes have been to emphasize the possibility of successful aging and to highlight the contributions that older people make to their families, communities and society as a whole.  

But presenting positive images of aging is not sufficient.  Illness and death are part of life, but they frighten a lot of people, and that contributes to negative feelings about aging. This translates to pushing people away, so we don’t have to think about illness or death. 

One place to start is to improve how we treat people with chronic illnesses, whether in their homes or in care facilities.  There are many excellent models of care that promote quality of life, but all-too-often programs settle for mediocrity or worse.  When we think of being old, we often think about ending up in a nursing home with not enough staff, low quality food, and rows of patients lining the halls strapped into their geri-chairs.  And, yes, that is a frightening and disheartening sight.  But it simply does not have to be the norm.  We have seen programs in different parts of the U.S. and in the world that counter that stereotype, with clean, well-lit facilities, high quality and comforting food, and staff who are devoted to the well-being of the residents.  The irony is that it does not have to cost more, it just takes a vision on the part of the program director to implement it.  

How have we managed to self-actualize in the face of negative stereotypes?  We both worked in fields, Judy as a psychotherapist and me as a professor, where experience was valued.  By being in the Gerontology field, we also know that what matters is quality of life, not quantity.  We try to make our choices, whether about where we live, what we do, or what we eat, based on what contributes to quality of life. 

There is a great deal of emphasis in the research literature and media on how to extend life or prevent specific ailments like heart disease or Alzheimer’s disease.  Unfortunately, many of these studies are flawed and make claims that go beyond what their data support.  We try to set a balance—regular exercise, reasonable diet, and staying involved, but we don’t become frantic trying to do everything.  We don’t want our last years to focus on doctors, medications, or detailed diet and exercise plans.   We feel that’s the key—the negative model of aging would have us focus on all the things that could go wrong.  We try instead to enjoy the gift that we have been given of a long life.