Thursday, November 7, 2019

Karen's Students questions

Steve saw this restaurant in Sweden recently

Our friend Karen Fingerman has again 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.  Karen and her teaching assistant selected 7 questions and sent them to us.  The students once again raised excellent questions. Here are the questions and our answers. 

 1.     How does the death of a partner in old age affect the aging process of the surviving spouse? 
– answered by Judy


This is one of those answers that must embrace individual differences, as we have seen a wide variety of responses to loss of a partner over the years.  Loss of a long-time life partner is always painful, as over time the two people usually have developed a symbiotic sort of relationship.  Whether the loss comes suddenly or after a period of decline, the finality of death forces the survivor to live in an altered reality not of their choosing.  They must make all of the decisions for themselves, after a life of shared decision-making (usually).  


As we think of the many people we have seen, there are probably two or three main patterns. One is for the surviving spouse to want to re-couple as quickly as possible.  We used to think it was mainly men who did this, responding to the casserole-toting widows and divorcees who seek them out, and wanting to find someone to take care of the details of everyday life.  But I have seen quite a few women who also want to remarry quickly, mainly because they cannot fathom not being part of a couple, and they want to resume that "couples" social life.  Once they have re-partnered, they imagine that they will return to their previous status quo.  Sometimes that is the case, sometimes not, depending on how the relationship works out.  For these people, the trajectory of their aging is largely not impacted.


A second group of people are those who have no desire to ever be in another relationship. They may believe that their partner was their lifelong love, and thus, irreplaceable.  Or, if there was an extended period of caregiving, they may not want to take that on again.  Some of these individuals go through an extended period of mourning, which validates the importance of their relationship, and comes to define them to the world. Eventually they may seek out same sex activities or resume previous friendships that do not challenge their decision to remain single. This allows them to develop a social support network that is likely beneficial to their mental and physical well-being.  Other people, however, isolate themselves in their grief, or they may have under-developed social skills that prevent them from joining in activities with others. These individuals are more vulnerable to premature aging, or to poor self-care that may lead to declines in health.


There's a third group we have seen, those who have large extended families, which serve the function of cushioning the isolation that might otherwise occur following the death of a spouse. If there are multiple generations in the family, they may find a helping role, such as caring for grandchildren or preparing holiday meals, that provides meaning and motivation to remain active and engaged in life.


In summary, there are multiple possible ways that loss of a spouse can affect individuals, and the mediating factor in how they navigate the aging process is probably social support.


2.  How does one come to terms with death?  What is the correct time to have a discussion about it? 
– answered by Judy


Having spend thirty years in practice and doing research with aging populations, we have a particular bias about this.  Death is a very natural part of life.  All living things die.  When our four-year-old or seven-year-old grandchild asks about death, we explain it to them in words they can understand.  They lost one of their grandparents about two years ago, when they were two and five.  They lost a great-grandmother six months before that.  They will inevitably lose other people.  Because none of our family has hesitated to respond to their questions, they have a basic understanding that will make it much easier as they go through life.  At times they are sad about it, but they are also accepting of it.  


Unfortunately, many people simply do not want to talk about death.  My father certainly could not.  But my mother, who was his caregiver, was eager to speak up about her wishes at the end.  In the past twenty years, Advanced Directives have become part of estate planning, which present people with the opportunity to designate which life-saving procedures they do or do not want in the event of a fatal situation.  These decisions should be made by the individual unless they are not competent to do so.  Ideally, Advanced Directives are made when the person is perfectly healthy so they can think about them objectively.  What is sometimes not done, however, is to explain exactly what those "life-saving" procedures are and what the consequences may be.  I actually spent a fair amount of time in my practice explaining those things, particularly to my clients who were in assisted living or skilled nursing.  


One way to initiate conversations about death and dying, and particularly end of life decisions, is to do so indirectly.  For example, when an acquaintance or friend of the family member dies, you can have a conversation about what happened and what they might want to have happen differently for them when the time comes.  By the time my mother died at nearly 92, she had seen many, many people die, and it helped her decide what she did and did not want at the end. Every time someone died, we would talk about it, and re-affirm her decisions.



3.  What should you do when differences of opinions arise in a family for end-of-life care? –answered by Judy
 This is related to the previous question.  The ideal situation is for the person who is dying to have already made those choices.  The next best choice is for the dying individual to have indicated who they wanted to make those choices for them.  My mother chose to move to be near me because she knew that not only did I know what she wanted, but that I wouldn't be afraid to follow through on her choices in the face of criticism from other family members.  As it turned out, by the time she died, the entire family was supportive of her decisions, which made our life simpler.  However, there are times when family members come forward with their own ideas that are different from either the dying person or their spouse, and that can cause needless emotional distress for the caregiver.


When decisions have not been made ahead of time, health care providers will sometimes be helpful in explaining exactly what the options are, but not always.  Sometimes they simply don't take the time, and sometimes their explanations are hopelessly medicalized so no one really understands them.  Some health care workers are uncomfortable talking about death and dying, too, and it causes them to either hold out false hope or to fail to respond realistically to family's questions.  In that case, if there is a social worker or psychologist available with expertise in end of life care, having a disinterested third party can help everyone come to a compromise agreement.

4.  In class, I have learned that stress does seem to age you faster as opposed to being carefree. As a 20 year old worried about her aging parents, how can I convince them to take advantage of vacation days without making them more stressed about missing out on work days? 
–answered by Steve and Judy

You ask a good question about the association of stress and aging, and it sounds like you want to have a positive influence on your parents.  It sounds like you already know that they do not readily take advice when it comes from their child.  That is very common in parent-child relationships.  One reason for this resistance is that parents still see themselves in the parenting role, no matter how old their children might be.  Their adult children give advice, but their parents don’t necessarily take it.  They also may resist changes, because they want to stay in control of their lives.  So when a child tells them what to do, they often resist, even if what the child proposes is a reasonable thing to do.

Instead of suggesting ways your parents might manage the stress in their lives, you might take a more indirect approach. When someone they know takes a vacation, you may show an interest in how those people have lowered their stress by using their vacation days effectively. Similarly, if you find an article (and there are lots of articles about stress and how to lower it), you might send that on to them. Lowering stress is about making conscious choices about how you use your time, and includes things like diet, exercise and self-care, so you can perhaps try to do some of those things yourself, and share your experiences about how it lowers your own stress.  When you bring up the subject by talking about what other people do, it is less challenging than giving advice, and less likely to be perceived as a criticism.

5.  Both of my mother’s parents had Alzheimer’s before they died. My mother has lived the majority of her adult life with the thought that she will most definitely get Alzheimer’s one day. How can I change my Mother’s mindset regarding her future with Alzheimer’s?
 –answered by Steve and Judy

All the publicity about Alzheimer’s disease and other degenerative brain diseases has been helpful in raising awareness and research funds, but the downside is that this attention also raises people’s fears.  For most people the risk of dementia is fairly low, at least until advanced ages (over 85), but that does not stop some people from worrying over each lapse of memory.  For someone whose parents both had Alzheimer’s disease, the risk is greater, and worrying about what may happen is understandable.

When people potentially have genetically-influenced disorders such as Alzheimer’s, the challenge is to live a full life as long as they are able.  In a way, we all face that challenge as we grow older, that is, we know something bad will eventually happen, but we don’t know when.  As we wrote in the previous example, you will have more success approaching your mother indirectly, rather than giving her advice.  There are a lot of articles about possible strategies for lowering risk of dementia.  You can pick out articles now and then and show it to your mother.  Or you might try one of the strategies yourself, like exercise or diet, which are good generally for health.  As we suggested above, your conversation with your mother can be about what other people have done, or your own experience, rather what she should do.  

When we started working in this field, over forty years ago, there was far less information about Alzheimer's disease and dementia.  The common view was that if you lived to a very old age, you might become senile, and that was to be expected.  As a consequence, not many people worried about it, perhaps because they correctly assumed they might die of something else before that time came.  As the dementias became better known, and the possibility of a genetic component became publicized, anxiety about the future began to increase in our client populations.  

Now fear of Alzheimer's is a standard feature of conversations among older people.  So while the actual numbers of people who get it have probably not changed, the number of people who are afraid they will has increased exponentially.  Trying to get people not to worry about what might not happen can be an exercise in futility, particularly in the face of the constant barrage of news articles about it.  We have seen the ravages of dementia up close, and neither of us would want that to happen to us.  But, of course, it could.  The odds are better that it won't though.  So the challenge is to find a way to think about it to ease the anxiety.  

Anxiety is a generalized worry about what might happen in the future.  One way to deal with it is to find aspects of the problem that you do have control over.  That includes making decisions about the future, should your mother become incapacitated. Now, while she is fine, is exactly the right time to do it.  Who would she want to make decisions for her if she was unable?  What kind of living situation would she prefer? Once these decisions have been made, she might be able to let go of worrying about it on a daily basis, knowing that she has done everything she can to plan for the future.  The best outcome would be if she decided to postpone worrying about it so that she can enjoy the present time with you.



6.  My biggest fear is to live a life full of regrets, only to realize those regrets didn’t matter in the end.What regrets do you wish you let go of as you’ve aged? 
–answered by Steve

This is wonderful question that gets at an issue, regret, which is widely discussed in literature, but not in adult development.  Regret highlights a major challenge that young adults face, how to know that the decisions you are making will lead you down the right path, or leave you feeling disappointed with your life.

We have had ups and downs in our lives, and we certainly have some regrets, but on the whole we feel good about what we have done and the choices we made. One reason is we were open to opportunities that arose.  For example, we moved across country when our children were still young to take new and better jobs and to live in a better environment.  Although we had time-consuming jobs, we found time to do the things we enjoy, such as traveling.  Judy says she has heard older clients say they regretted not having taken trips, but no one ever told her they regretted taking trips.

One thing we have always been able to do is make decisions quickly.  Once we get a sense of what we think is the best choice, we move ahead.  I probably do a little more mulling on decisions than Judy, but we almost never have gotten stuck.  Some choices have not worked out as well as we hoped, but we don’t find ourselves dwelling on regrets.  Instead, we are able to enjoy the good things in our lives.  

In the next few years, you are likely to face a lot of decisions that will affect the course of your life.  If you tend to get stuck trying to make decisions, there is a strategy that will help.  Divide a piece of paper into two columns and write down the pros and cons of the choice you have.  Doing pros and cons can help you organize your thoughts, and weigh more carefully whether to proceed or not.  You can also see if you need more information before you make your decision. 

You can also use pros and cons if you tend to be impulsive and find yourself regretting hasty decisions? Do you rush into relationships or purchases or other things?  You might want to make a rule that you won’t make big decisions without taking some time to think things through.  Doing pros and cons will give you time to sort out your thoughts and look at the possible risks and gains.  


7.  How do you prevent social, emotional, and physical isolation in old age? 
answered by Steve

This question focused particularly on the isolation that can occur following placement in a nursing home.  People who are moved into nursing homes are cut off from family and friends, and are likely to experience feelings of loneliness and isolation.  Many nursing homes welcome visitors, but some do not or do not provide places where the resident and friends can comfortably visit.  For many people, visiting a friend or relative in a nursing home is upsetting.  They do not want to be around people who are old and sick, or have trouble figuring out what to say or do with their friend or relative. And no matter how skilled and caring the staff may be, the social activities they organize in a nursing home will not replace a resident’s long-standing relationships or the comfort of one’s own home.

Nursing homes can take some practical steps to help foster visits from family and friends.  At the time of placement, a staff member can give family members an orientation to the facility, talking about the importance of visiting and helping families think about what they might do or say during the visit.  Family may feel guilty for placing a parent or spouse, and being able to talk about that can help them get past feelings of awkwardness about visiting.  Staff can also be supportive of visits, making sure the visitors feel welcomed and getting to know the visitors. Better facilities have support groups for family members, often led by a member of the social services staff.

An unfortunate aspect of most US nursing homes is that residents live in small rooms with one or sometimes multiple roommates.  The lack of privacy leads people to withdraw within themselves, and makes visitors uncomfortable.  Although it is not likely that facilities will suddenly change to single rooms, they should be able to provide an attractive place for visits, including private areas away from other residents and blaring televisions.  Single rooms are the norm in most economically-advanced countries, but that is another discussion.

Of course, the biggest obstacle to these strategies for reducing isolation is cost.  The argument will be that staff are too busy or that space is simply not available or that family simply do not want to visit.  But we have been in facilities that provide care in a welcoming, attractive, and homelike setting, and where staff emphasize their interactions with residents and their families.  When you find a special facility like that, talk it up or write a letter to your local newspaper or on a social website.  


1 comment: