Chapter 15.PDF

Chapter 15 Gains and Losses in Late Adulthood Learning Objectives After reading this chapter, you should be able to: 15.1 Describe typical physical, cognitive, and socioemotional changes and challenges in late life and identify coping strategies that pro- mote healthy adap...

Chapter 15 Gains and Losses in Late Adulthood Learning Objectives After reading this chapter, you should be able to: 15.1 Describe typical physical, cognitive, and socioemotional changes and challenges in late life and identify coping strategies that pro- mote healthy adaptation. 15.2 Explain the process of death and issues associated with dying, including the dynamics of the grief process and grief coping mech- anisms, and develop supportive, personalized interventions for coping with bereavement. At age 81, Helen still maintains her job in a bookstore. As one of the oldest siblings in a large working-class family, she learned early to value hard work and has always been active and productive. Her job provides her with opportunities to maintain her skills as well as the chance to learn new ones, such as the new computerized s­ ystem her company uses to inventory material. Helen is fortunate in that her health is good, aside from some problems with arthritis that slow down her movement. She ­recognizes that she must regulate her activity now more than before, reducing e­ xtraneous activities so she can be well rested and prepared for work, thus optimizing her performance there. She is an avid fan of crossword puzzles; they are part of her recipe for staying mentally active. When she noticed herself becoming more forgetful, she compensated by writing notes to herself and establishing and following set routines. She travels and volunteers less these days, compared to what she did years ago when her h ­ usband was alive. Now she chooses to spend more time with her two children and their young families, and she makes sure to take walks several times a week to keep herself ­physically active. She knows what she can do, and she focuses on the activities that give her a sense of satisfaction. Helen’s adaptation is a good example of how a person can cope successfully with the challenges of aging. As people move into old age, in their 60s and 70s, or into ­old-old age, in their 80s and 90s, both gains and losses continue. However, losses may considerably outweigh gains. “Even in young people’s lives, not everything goes well. Old age is a genuinely difficult situation with lots of sadness and frustration. Many things do not go well” (Pipher, 1999, p. 26). How can the elderly effectively manage the ever-increasing losses they experience? For example, can their develop- mental ­trajectory be a positive one when they experience multiple health problems or find themselves in chronic pain? An important focus of this chapter will be to identify the means by which older adults manage their lives and the extent to which they can grow, maintain themselves, and regulate their losses. Clearly, different people manage their late-life losses with varying degrees of ­success. But you may be surprised to learn that for a majority of us, successful devel- opment is what we can expect for much of our old age. In what follows, we will first 591 592 Chapter 15 FIGURE 15.1 The growing aging population across the world. The numbers of aged are predicted to rise sharply across the world in coming years. 2000 80 or over 60–79 1500 Population (millions) 1000 500 0 1980 2017 2030 2050 1980 2017 2030 2050 1980 2017 2030 2050 1980 2017 2030 2050 World More developed regions Less developed regions Least developed countries SOURCE: United Nations World Population Aging 2017, United Nations Department of Public Information` retrieved from www.un.org/en/development/desa/­ population/publications/pdf/ageing/WPA2017_Report.pdf. review the nature of the losses and challenges that typically confront people in old age. Then we will look at the ways in which older adults cope with these challenges, paying special attention to the processes that seem most important for the life-long experience of psychological well-being. The fact that the world’s aging population is rapidly increasing adds a level of urgency to these issues if we are to support healthy development at all points in the life span (see Figure 15.1). Physical, Cognitive, and Socioemotional Change in Late Life 15.1 Describe typical physical, cognitive, and socioemotional changes and chal- lenges in late life and identify coping strategies that promote healthy adaptation. Challenge and Loss in Late Adulthood PHYSICAL CHANGE A gradual decline from peak functioning is characteristic of most physiological sys- tems beginning as early as age 30. By late adulthood, the losses are usually noticeable and have required some adjustment in expectations or lifestyle. A life-long runner who still entered marathons at age 62 remarked, “At 30, my goal was to win. At 50, I cel- ebrated every race that I finished. Today, I’m delighted to be at the starting line.” Maintaining good physical and mental health becomes more challenging with age, as the immune system grows progressively less effective in staving off cancer and infections, and as the cardiovascular, respiratory, and organ systems decline in their functioning. Rates of chronic illness increase dramatically with age, as does the need for more vigilant health maintenance. Age shifts in the leading causes of death illus- trate these changing health concerns. In the United States, accidents are the leading cause of death in adults up to age 45. But at 45, heart disease and cancer take over as the leading causes of death, followed by cerebrovascular diseases and chronic respira- tory illness (U.S. National Center for Health Statistics, Health, United States, 2017).  Gains and Losses in Late Adulthood 593 People of any age can suffer from acute or chronic illnesses, such as cancer, heart prob- lems, or diabetes. But the risk of these illnesses climbs dramatically and steadily in our later years. Among the continuing declines of old age, two are common and often especially debilitating. First are increasing sensory deficits (see Chapter 13). Changes in the visual system can be particularly important for one daily activity: driving. A num- ber of aging changes make driving more difficult, including loss of visual acuity, loss of sensitivity to movement in the periphery, increased recovery time after exposure to glare, and reduced night vision. These changes occur gradually starting in middle adulthood but do not contribute significantly to accident rates until people reach their mid-70s (U.S. Bureau of the Census, 2012; Whitbourne, 2002). A second important decline in older adults is the onset of arthritis, with its atten- dant pain, stiffness, and swelling of joints and surrounding tissues. After 65, about half of women and about 40% of men experience the most common form, osteoarthritis, which involves the thinning, fraying, and cracking of cartilage at the ends of bones. Ordinarily, this cartilage helps protect our joints from the friction of bone-to-bone con- tact. As cartilage degenerates and other joint changes occur, such as the growth of bony spurs and modifications in connective tissues, joints may stiffen and swell. This leads to pain and reduced movement. Being overweight or overusing a particular joint (for example, the knees in sports like running and tennis) can contribute to suscepti- bility, but ordinary degeneration with age is part of the problem. Osteoarthritis can range from being a painful nuisance to being a source of major disability. It can affect the performance of simple tasks, such as opening a jar or walking, as well as more complex skills, such as playing the piano or swinging a golf club (Hunter, McDougall, & Keefe, 2008). How older individuals respond to daily physical symptoms has a substantial impact on their overall health over time. Being proactive in seeking help when health problems begin and making a strong commitment to treatment, such as sticking to medical treatment plans or exercise regimens, is important. In a longitudinal study of people above age 60, Wrosch and Schultz (2008) found that the use of such health man- agement control strategies was directly related to health maintenance versus decline. We have repeatedly examined the role of stress in inflammatory and disease-related processes throughout the life span. In old age, stress-related allostatic load contrib- utes to disease burden and lowered quality of life (Prasad, Sung, & Aggarwal, 2012). Of particular significance are studies that implicate stress in telomere shortening. ­Telomeres are the protective ends of chromosomes that are shortened by physiological and psychological stress as well as age. When stress is chronic, accelerated cell aging has been observed in both children and adults. Shortness of telomeres is associated with earlier mortality (Lin, Epel, & Blackburn, 2011), but some shortening may be reversed with effective stress management strategies such as mindfulness meditation (Deng, Cheung, Tsao, Wang, & Tiwari, 2016). Not all stress is bad, however. Exercise is a beneficial form of physical stress that provides abundant benefits for all age groups. Physical activity may involve sports and regular exercise, but also includes things like walking a pet or gardening. Remaining as active as possible in later life, both through structured exercise and physical activities, helps reduce stress and promotes health. Other mild forms of physiological stress, such as the stress of caloric restriction and exposure to cognitive stimulation, also appear to reduce deterioration in aging indi- viduals (Mattson, Chan, & Duan, 2002). BRAIN AND COGNITIVE CHANGE Cognition depends on a healthy and well-functioning brain. This means, among other things, that synaptic connections operate smoothly and the integrity of white matter is preserved. You have seen that healthy brain development proceeds in an organized fashion, with the frontal lobes being the last to mature. As people age, those portions of the brain that matured last tend to be most vulnerable. Vascular problems and atrophy affect the frontal lobes first in late life, although this phenomenon does not account for all the cognitive changes of aging (Mather, 2016). Thus, executive functions, largely controlled by the frontal lobe, are areas that generally show the earliest age-related 594 Chapter 15 declines. Continuous decrements on many neurological measures related to cognition like brain volume, cortical thickness, neurotransmitter efficiency, and so forth extend from the decade of the twenties onward (Salthouse, 2009). In this section we’ll take a look at these changes and provide a brief review of related material from Chapter 13. You probably recall that researchers make a distinction between fluid and crystal- lized intelligence as a way of describing two types of intellectual resources. In previous chapters we called these categories mechanics (fluid) and pragmatics (crystallized). Another way to think about this distinction is to consider fluid intelligence as the pro- cessing efficiency of the cognitive system and crystallized intelligence as the product of that processing (Salthouse, 2006). For many years, cross-sectional studies of cogni- tive aging in adults have reported declines in both fluid and crystallized intelligence (Jones & Conrad, 1933; see Figure 15.2a). Longitudinal studies paint a different picture. They suggest that crystallized intel- ligence, as represented by measures of verbal ability and factual knowledge, does not decline until the mid-70s, and the declines are modest thereafter (Schaie, 1996). Many old individuals show no declines in some areas, and some who have maintained good health actually continue to improve on crystallized intelligence measures. For exam- ple, in one longitudinal study of 70- to 100-year-olds, vocabulary knowledge increased until age 90 and showed only slow declines thereafter (Singer, Verhaeghen, Ghisletta, Lindenberger, & Baltes, 2003). In contrast, gradual decrements in fluid intelligence, marked by slower processing speed and reduced inhibitory functions, do occur with age. Such declines may limit the efficiency of working memory operations, such as learning and problem solving, but these effects may be balanced by the maintenance or advancement of crystallized intelligence or pragmatics (see Figure 15.2b). Interestingly, even for people who perform well on cognitive tasks into old age, there appear to be changes in the areas of the brain that are being activated. In brain imaging studies, older adults frequently show less activity of some brain sites and more activity of other sites, especially the prefrontal lobes, relative to younger adults. Also, older adults are more likely to involve both sides of the brain in performing a task whereas younger adults may only use one side. There could be many reasons for these differences in brain utilization, but some evidence indicates that compensation for loss is often involved, helping the older individual to maintain levels of perfor- mance. This is a little like using a back-up reserve and can be successful at moder- ate levels of task difficulty. When the demands exceed capacity, a resource ceiling is reached, which might explain age-related cognitive declines (Reuter-Lorenz & Park, 2014; Sala-Llonch, Bartres-Faz, & Junque, 2015). Despite the fact that longitudinal results have been the dominant paradigm for interpreting age changes in cognition, some researchers have questioned the accuracy of these results. Salthouse (2009) showed that reanalyzing the longitudinal data while extracting the effects of prior testing or “practice effects” changes the picture. After sta- tistically removing the practice effects, results from longitudinal findings more closely mirror the declines observed in cross-sectional analyses. These findings, however, should not diminish the importance of longitudinal work. They do suggest, however, the need to more clearly identify true maturational change, devoid of practice effects, and to factor in the developmental stage at which the learning occurs relative to when it is lost. Other recent work has indicated that different cognitive abilities may peak at different ages, and that the distinction may be more complex than the simple distinc- tion between fluid and crystallized intelligence (Hartshorne & Germine, 2015). Craik and Bialystok (2006) offer a framework (see Figure 15.2c) for understanding age changes in cognition that integrates cross-sectional and longitudinal results. These authors use a different way of characterizing cognitive functions: r­ epresentations and control. Representations are the kinds of schemas or systems of schemas one devel- ops over time to interact with the world. In previous chapters we described Piaget’s famous stage theory, a narrative of how representations develop from reflexes to abstract thought across the years of childhood and adolescence. Representational sys- tems can involve declarative (language or world history) or procedural (playing chess or driving a car) knowledge. Representations are the foundation of crystallized intel- ligence. Control involves the ways one works with knowledge and includes attention,  Gains and Losses in Late Adulthood 595 FIGURE 15.2 Three models of cognitive change throughout the life span. Part a reflects an inverted u-shaped curve of cognitive development. Performance increases in ­childhood, is maintained in adulthood, and decreases thereafter. Part b illustrates differing trajectories for fluid and crystallized intelligence. Part c incorporates executive processes informed by neurosci- entific findings that show more subtle patterns of maintenance and decline. (a) Performance Childhood Maturity Old age (b) Crystallized pragmatics Performance Fluid mechanics Childhood Maturity Old age (c) Representations Practice Access Performance Control processes Childhood Maturity Old age SOURCE: Republished with permission of Elsevier Ltd. from Cognition through the lifespan: Mechanisms of change. Trends in Cognitive Sciences, Based on Craik, F. J. M. & Bialystok, E. (2006). 10, 131–138; permission conveyed through Copyright Clearance Center, Inc. learning efficiency, and flexibility of working memory, inhibitory control, and process- ing speed. Both representations and control features interact. Consider how your atten- tion is drawn to certain kinds of information, which, in turn, results in the construction of new schemas or representations of the world. As your understanding grows in a particular domain, so does your expertise. At older ages, the process of forming new representations is more challenging despite the retention of previously learned representational systems. It appears that using these systems contributes to their maintenance, supporting the proverbial “use 596 Chapter 15 it or lose it” advice. But even previously learned representations depend upon control functions in order to be accessed and used. For example, the name of that elementary school classmate you’re trying to recall does you no good buried in your memory unless you can access it. Peak levels of cognitive control functions occur in young adulthood, and gradually decrease thereafter. Craik and Bialystok posit that research on cognition in childhood and late life are separated by differences in language and emphases. “In development, the primary emphasis is on the changes in representations as the child constructs a coherent inter- pretive basis for understanding the world; in cognitive aging, the primary emphasis is on decline in control processes as they produce impairments of access to existing knowledge, integration of new and existing information, and translation of knowl- edge into timely and adaptive action” (Craik & Bialystok, 2006, p. 136). But a more holistic approach to cognition and, in particular, to executive functions across the life span can help us map existing knowledge onto new findings in neuroscience. This approach also offers a potential paradigm for studying remediation efforts to increase cognitive reserve (Reuter-Lorenz & Mikels, 2006). Dementia. Dementia is a syndrome that affects multiple functional domains due to chronic and progressive disease processes in the brain. Cognitive and emotional skills like memory, judgment, language, self-regulation, and motivation diminish progres- sively. Alzheimer’s disease (AD) is the most common type of dementia, accounting for 60% of all cases. Frontotemporal dementia (deterioration primarily in frontal and temporal lobes), vascular dementia (related to problems with blood flow to the brain), and dementia with Lewy bodies (or protein build-up) also account for many cases. Among these four main types of dementia, there is a great deal of overlap, and com- bined types are frequent (World Alzheimer Report, 2009). An estimated 46.8 million MyLab Education people around the world were living with dementia in 2015, and rates are predicted Video Example 15.1 Alvin, diagnosed with Alzheimer’s to double every 20 years (World Alzheimer Report, 2015). In the United States, it is a year ago, and Susan, his partner estimated that there will be over 13 million Americans diagnosed with AD by 2050 and primary caretaker, describe the (Smith, 2016). challenges of living with dementia. Alzheimer’s disease is diagnosed primarily by its clinical characteristics and by excluding other possible causes of dementia. Diagnostic procedures are being improved continually, and skilled clinicians can diagnose quite accurately following a comprehensive evaluation. At this point, however, only autopsy can definitively conclude the presence of AD. Typically dementia progresses in stages. There is a pro- dromal period, lasting for a year or two, when symptoms like memory loss fall short of a clinical threshold but do present more impairment than normal for that age. In its early stages, AD looks like absentmindedness: forgetting where you recently put something or forgetting an event that happened in the last few days or even the last few hours. Difficulties with decision making, word finding, regulating moods, or completing complex tasks might be present. Some pharmaceutical treatments are currently being tested for symptom reduction at this stage, but, thus far, daily exer- cise and cognitive stimulation have shown the greatest benefit (Cheng et al., 2012; Morley, 2011). More general confusion may follow in the middle stage (second to fourth or fifth year). Individuals might have difficulty remembering even very recent events, wander away from home and get lost, or lose the ability to prepare meals or perform other self- care tasks. People at this stage may be quite distressed by their memory loss, perhaps even paranoid if they frequently cannot remember what they have done or where they have put things. They may also conclude that others are responsible for these lapses. A relative of one of the authors, for example, would insist that people had entered her apartment and had turned on her TV when she wasn’t looking. Others may become hostile in their frustration and confusion. One elderly man, believing that an intruder had entered his home, assaulted his own son each time the latter visited. In later stages, memory and language problems worsen, disorientation is extreme, and physical coor- dination deteriorates. Eventually, in the last stage (fifth year and after), Alzheimer’s patients are often mute and bedridden, needing full-time care and supervision. The disease eventually causes death (Alzheimer’s Association, 2012).  Gains and Losses in Late Adulthood 597 This is not the only course of the disease. Early-onset AD strikes 40- to 50-year-olds, ends in death after about five years, and clearly has a genetic contribution. In all forms of AD, extensive brain changes include the formation of plaques, clumps of insoluble protein that are damaging to neurons, and tangles, twisted filaments of another pro- tein, which may interfere with communication between neurons and even cause cell death (Braak & Braak, 1991). Amyloid precursor protein (APP) and several enzymes that operate on it appear to play an initial role in the development of plaque formation (Ballard, Gauthier, Corbett, Brayne, Aarsland, & Jones, 2011). Related inflammatory processes may also act as important precursors of dementia. These inflammatory pro- cesses can start 10 to 20 years before actual symptoms appear (Friedrich, 2013). Early stage studies have also found noticeable brain changes in AD, including thinning in several areas of the brain (Pegueroles et al., 2017). The inability to remember things after an intervening distraction or period of time (either several minutes or longer), called delayed recall, is considered one of the best preclinical signs of approaching AD (Salmon & Bondi, 2009). Many of us have seen the ravages of dementia in a relative or friend, and we worry that extreme memory loss and disorientation are inevitable consequences of aging. But they are not. Normal aging does not lead to dementia, although the frequency of ill- nesses and conditions that cause dementia does increase with age. Among these are cardiovascular problems that limit the oxygen supply to the brain for some period of time. These include cerebrovascular accidents, or strokes, in which an artery serv- ing the brain is either clogged or bursts. A single stroke can lead to acute onset of dementia. More typically, many minor strokes (multi-infarct dementia) can gradually do sufficient damage to cause dementia. Hypertension (high blood pressure) or hyper- tension combined with diabetes, increase the risk of multi-infarct dementia (Venkat, Chopp, & Chen, 2015). Although AD and other forms of dementia do not affect the majority of older adults, there is some suspicion that the formation of plaques and tangles may occur to some extent as a normal aging process in all of us. Some environments seem to enhance or reduce AD rates. For example, life-long education and intellectual stimula- tion seem to decrease the risk (Snowdon, 1997; Wilson et al., 2010). Rates of AD and other dementias are substantially higher in low-income compared to high- and mid- dle-income countries (World Alzheimer Report, 2015). While there are no known treatments for diagnosed AD, advances in research since 2010 have shed light on promising strategies for prevention and intervention prior to diagnosis. Specifically, three different classes of interventions have been identified: cognitive training, general health interventions like blood pressure man- agement in individuals with hypertension, and increased physical activity (National Academies of Sciences, Engineering, and Medicine, 2017; Smith, 2016). The strongest evidence exists for cognitive training and stimulation to delay or slow the progression of age-related cognitive decline. This cognitive training and stimulation can involve formal programs as well as more informal activities or hobbies, like reading, knitting, and doing crossword puzzles. Increased physical activity and exercise may delay cog- nitive aging in general, and it may also prevent or delay worsening of symptoms in individuals with mild cognitive impairment, a precursor of dementia (Smith, 2016). Other strategies for individuals showing preclinical dementia include cognitive train- ing interventions to encourage active cognition and practice, and also evidence-based treatments like cognitive behavioral therapy for individuals with comorbid depres- sion (Orgeta, Qazi, Spector, & Orrell, 2015). Perhaps not surprisingly, all the promising avenues for preventing or delaying the development of dementia have more general benefits for the health and well-being of older adults. Mounting evidence supports the importance of regular physical activity for older adults. In a recent longitudinal study of leisure-time physical activities in a sample of over 1,000 older adults, researchers found that engaging in regular moder- ate to high intensity physical activity predicted slower cognitive declines in areas of processing speed and episodic memory, even when controlling for initial differences in health conditions like high blood pressure and health-related behaviors like smoking (Willey et al., 2016). Other recent work supports the findings that physical activity may 598 Chapter 15 especially slow declines in cognitive abilities associated with the prefrontal FIGURE 15.3 The relationship between survival scores on an IQ test of cortex and hippocampus (Prakash, Voss, Erickson, & Kramer, 2015) and that verbal meaning in a longitudinal study. higher levels of aerobic physical activity predict greater cognitive benefits, in a dose-response relationship (Vidoni et al., 2015). Score Cognitive aging also may be reduced or delayed among older adults 20 with specific cognitive training. A meta-analysis of 49 studies examining approaches to cognitive training, such as computerized practice in domain- specific skills of working memory, demonstrated overall positive effects for 15 improved performance on the trained tasks as well as near-transfer (i.e., very similar) tasks (Karbach & Verhaeghen, 2014). Other studies have indi- cated that, with practice, older adults can improve their performance on 10 visual and perceptual learning tasks (DeLoss, Watanabe, & Andersen, 2015). It is important to note, however, that these specific training paradigms do not appear to improve more general cognition. Interventions that target 5 multiple aspects of well-being (such as diet and exercise, cognitive train- ing, and engagement in hobbies and social relationships) are most likely to reduce risk for dementia and show measurable benefits for individual older 0 adults (Smith, 2016). 70 75 79 Age Terminal Drop and Terminal Decline. Terminal drop and terminal Still alive 81 Dead 79−