A hermeneutic phenomenological explorations of living in old age

Geriatric Nursing xx (2017) 1e9

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Feature Article

A hermeneutic phenomenological explorations of living in old age Ma. Ángeles De Juan Pardo, RN, MSN, PhD a, *,1, María Teresa Russo, PhD b, c, María Victoria Roqué Sánchez, PhD d, e a

Department of Nursing, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain Department of Educational Sciences, Roma Tre University, Rome, Italy Institute of Philosophy of Scientific & Technological Practice, Campus Bio-Medico University, Rome, Italy d Department of Humanities, Universitat Internacional de Catalunya, Barcelona, Spain e Department of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain b c

a r t i c l e i n f o

a b s t r a c t

Article history: Received 4 December 2016 Received in revised form 27 April 2017 Accepted 29 April 2017 Available online xxx

Although there have been some studies that explore the meaning of aging and give voice to older people, the impact that the aging experience can have on them justifies continued research in this area. In this study, with a hermeneutic phenomenological design and an interpretation method inspired by the philosophy of Ricoeur, we conducted in-depth interviews with 14 elderly people at a social day center in Rome (Italy). The analysis revealed three central themes associated with the experience of being old: changes and limitations related with being aged, the experience that comes from having lived a long life, and an awareness of death. The findings could help health professionals, families and caregivers to achieve a deeper understanding of what old age entails, and may also serve as a platform for interventions that seek to enable older people to experience aging as a meaningful and positive process. Ó 2017 Elsevier Inc. All rights reserved.

Keywords: Aging Phenomenology Hermeneutics Qualitative methods Ricoeur

Introduction The world’s population has aged significantly in recent decades. Currently, around 12% of people worldwide are over 60, although this figure is expected to surpass 21% by 2050, meaning that it will have more than tripled since 2000.1 Alongside this increase in the number of older people one must also consider the phenomenon of longevity:2 the size of the over-80 age group is increasing markedly, and new terms such as ‘old old’, ‘oldest old’3 and ‘fourth age’3,4 are now commonly used to refer to advanced old age. The achievement of greater longevity has, of course, been accompanied by the consequences of biological aging. One of these is the increased prevalence of age-related chronic diseases such as dementia and vascular disease, which in many cases lead to disability and dependence.5

Conflict of Interest statement: No conflict of interest has been declared by the authors. Funding Statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. * Corresponding author. Department of Nursing; Universitat Internacional de Catalunya Josep Trueta s/n, 08195 Sant Cugat del Vallès, Barcelona. Spain. Fax: þ34 935042001. E-mail address: [email protected] (Ma.Á. De Juan Pardo). 1 SARX (Research group in anthropology of embodiment - 2014 SGR 835). 0197-4572/$ e see front matter Ó 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2017.04.010

Predominant values of Western society, such as autonomy and productivity, may generate an extremely negative social perception of aging.6 Ageist attitudes of this kind can place older people in a highly vulnerable situation and heighten the risk of social exclusion. Furthermore, with age, people may end up internalizing these negative stereotypes, and as a result of these internalizations may actually begin to present signs of, for example, failing memory, cognitive confusion or physical frailty.7 Older people also frequently perceive themselves to be a burden on their families and on society.8,9 It should be noted, however, that there are also salutogenic perspectives10,11 which highlight the positive and enriching aspects of aging. Although there have been some studies that explore the meaning of aging and give voice to older people the impact that the aging experience can have on them justifies continued research in this area. In this respect, the present study focuses specifically on the aging experience of semi-independent old-old and oldest-old adults. Literature review The meaning of aging has been studied from a range of perspectives. More than 300 biological theories have been proposed to explain the etiology of cellular aging in the organism.12e14 All of them seek to identify the factors that stimulate the morphological

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and functional impairment associated with aging, the overall aim being to slow or even prevent this process. An analysis of these theories suggests that the causes of physiological aging, at least as we know them today, are multifactorial.15 Psychosocial theories of aging apply a broader perspective to the aging process, considering other dimensions of the person and making proposals for helping older people to adapt positively to aging. Among these theories, Erikson’s stages of development theory16 and Tornstam’s gerotranscendence theory17e19 stress the new perspective that can be achieved in old age, which they regard as a possible stage in the process of growth toward maturity and wisdom. However, as the founders of these theories point out, this wisdom and maturity can also be achieved at other stages of life, and therefore the question of what the specific meaning of old age is remains unresolved. To date, few studies have focused on the overall experience of being old.20e24 Nevertheless, and despite the fact that they are mostly descriptive, they provide interesting insights into the phenomenon. In particular, they indicate that living with loss, life experience, increased religiosity and spirituality, and uncertainty about the future are all aspects to be considered when caring for older people. Understanding the experience of being old from the point of view of older people, and exploring the meaning of old age, is crucial to the provision of patient-centered-care. In this study we aimed to address these goals by considering the following questions: a) What is the nature of old age? b) How is old age experienced by those living it? Method We carried out a hermeneutic phenomenological study inspired by Paul Ricoeur’s theory of text interpretation,25e27 as described by Lindseth and Norberg.28 This approach was chosen for two reasons. First, in his theory of the hermeneutic arc between explanation and understanding, Ricoeur describes a three-stage process of analysis (initial or naïve reading, structural analysis, and comprehensive interpretation) in which the interpreter moves from a naïve to an in-depth understanding of a text. This process will be illustrated later. The second reason for drawing upon the work of Ricoeur has to do with his discussion of the relationship between narrativity and temporality.29 According to Ricoeur the purpose of interpretation is not to explore a person’s psychological intentions with regard to a particular experience, but rather to reveal the meaning of that experience through an analysis of discourse. Thus, in the texts considered in this study (both the interview transcripts and the results of the structural analysis) the discourse follows an order, a new temporality that produces what Ricoeur refers to as ‘refiguration’, that is, the transformation of lived experience through narrative. It is this that gives meaning to experience and which enables a more in-depth understanding of a phenomenon to be reached. Participants and setting for the study Participants were recruited by means of convenience sampling from the “blinded for review”, a social day center (SDC) in Rome (Italy). Purposeful sampling was also carried out, with the aid of the social worker at the center, in order to obtain some variability in terms of the social class and educational level of participants, and also to obtain ‘good informants’ able to provide a sufficiently ‘complete’ description of their experience of being old. Inclusion criteria were: a) age 75 or above; b) ability to speak Italian or Spanish; and c) provision of informed consent to participate. Exclusion criteria were cognitive inability to participate or a major

acute pathology at the time of the interview. During data collection the main researcher acted as an outside observer and facilitator, helping participants to narrate their life experiences during the interviews. Data collection Data were collected through phenomenological interviews with older people regarding their lived experience while advancing in age. Data collection was stopped once the authors considered that further interviews would not yield any additional comprehensive data for understanding the phenomenon. A flexible interview guide was used (see Table 1), with questions designed to help the interviewee narrate his or her experience of being old. This guide proved useful for avoiding digressions (e.g., long accounts of the individual’s personal biography, general thoughts on the subject of old age, or comments about changes in society). Field notes were also taken during the interviews and during visits to the SDC regarding non-verbal language, the environment, and the context. Analysis Ricoeur’s theory of text interpretation.26 proposes three stages or levels of analysis. The initial reading of a text produces a first ‘naïve’ interpretation of the phenomenon under study. For this stage we did several readings with an open-minded approach in order to identify expressions and words in the interview transcripts that referred directly to the experience of aging. It was here that the first conjectures about the meaning of the experience of being an older person emerged. The second stage is the structural analysis, a systematic method that identifies and explains the issues and the main structure of the essence of the phenomenon. For this stage we performed a content analysis of each transcript. We began by identifying units of meaning, which were then grouped and condensed to form categories. Main themes were then identified by analyzing the relation between the different categories. In this way we identified the structure of the phenomenon under study: the lived experience of being aged. Transcripts of interviews and field notes were analyzed simultaneously with data collection from subsequent interviews, thus enabling more questions to be added to the interview guide as the study progressed. The aim of the third stage of analysis is to obtain a comprehensive understanding of the phenomenon and its possible

Table 1 Interview guide. Main questions: I would like to know about your experience of being xxx years old. Could you describe what your days are like? For example, what did you do yesterday? Can you tell me what it means to you to be old? What changes do you associate with this stage of life, compared with previous stages? What do you think is the best thing about old age? And the worst thing, or the most difficult thing? How do you feel at the age of XX? Thinking of the last two weeks, can you remember a situation that struck you particularly regarding the issue of old age? In your answer to the previous question you talked about a positive (negative) situation. Can you now tell me about a negative (positive) situation caused by old age? Has anything happened in the last week that has made you feel old? What advice would you give others about life from the perspective of someone who is x years old? On the sign in the entrance it says “Health Center for the Elderly”. What comes to mind when you hear this expression?

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meanings. This involves a more in-depth interpretation in which the results of the initial reading are correlated with those of the structural analysis and the literature review in order to reveal the meaning of this life stage. It is here that we enter the hermeneutic arc, moving back and forth between understanding (through an inductive method) and explanation (through a rigorous and systematic scientific method). Since the themes identified and their possible meaning are compared and contrasted with the literature, the comprehensive analysis forms part of the discussion section below. In order to conduct a more objective analysis we sought to allow the text to ‘speak’ through the three stages of analysis. Three strategies were used to ensure the reliability of our approach. First, after conducting and analyzing the first set of interviews we drew up a series of questions (based on this analysis) for inclusion in subsequent interviews. These questions referred to the themes identified in the initial analysis. This process continued until data saturation was reached with respect to the main themes. Second, once we suspected that data saturation had been reached, a new interview was conducted to verify this. Third, the phenomenological account was read to one of the participants, and to some of the SDC staff, in order to ensure that it offered a complete and meaningful description of the experience of being aged. If the study has sufficient credibility, then both older people and those who have daily contact with them should recognize the descriptions or interpretations as typical of this stage of life. The final phenomenological narrative about the experience of old age was also read to one of the participants, who confirmed that she understood it and that it corresponded to her experience. At all events, and as Ricoeur points out, the aim is not to obtain absolute certainty when interpreting the meaning of an experience, but rather to reveal the possible significance of a phenomenon.26 In the final presentation of results, each theme

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was illustrated through the inclusion of verbatim statements from the transcripts. Ethical considerations The study was approved by the ethics committee and the doctoral sub-committee at the Universitat Internacional de Catalunya, where the project was submitted. In addition, permission for data collection was obtained from the managers of the SDC where the interviews were conducted. Participants received oral and written information regarding the study prior to giving their consent to take part. They were assured that they could withdraw from the study at any time and that their confidentiality would be maintained. Findings Interviews were conducted with 14 older people between January and May 2010 and recorded and transcribed verbatim by the first author. The interviews, which lasted between 45 and 90 min, began with administration of a sociodemographic questionnaire (see data in Table 2), during which time the participant’s answers and comments concerning age, level of schooling and so on were also tape recorded. Participants were 12 women (10 widows and 2 single) and two men (both widowers), aged between 75 and 96 (median ¼ 84 years). In terms of education, seven of those interviewed had only completed primary school, while four had finished secondary school. Only three had attended university. These data are consistent with the cohort, for as one of the participants said during interview, “we didn’t go to school back then” (P6). Two participants stated that they forgot things more easily than before, but as neither of them had been formally diagnosed with cognitive impairment they were not excluded from the study.

Table 2 Demographic characteristics of participants. Participant Sex and age

Living situation

Education

Employment prior to retirement

Hobbies

Health problems reported

P1

With children, widow With children, widow With children, widow Alone, single

Primary school Primary school Secondary school Secondary school Primary school Primary school University

Shop worker

Reading, sewing

Femur fracture, tremor, hearing loss

Domestic service

Reading, sewing

Joint pain, visual deficit, heart problems

Community service

Exercise, volunteering, playing cards Femur fracture

Worked in a shop

walking, radio, television (TV)

Back pain, breathing problems

Housewife

Sewing, go to the park, housework

Sales representative

Walking, TV, theater, playing cards

Joint pain, hypertension heart problems, joint pain None

Community service

Sewing, TV

None

Domestic service

Sewing, read newspaper, etc.

Anemia, digestive problems

Community service

reading, walking, manual work

Diabetes, registered disabled

Domestic service

Exercise, read the newspaper

Heart problems

Community service

TV, read the newspaper, theater, singing, etc. Radio, singing

Joint pain, tremor

P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14

F 85 F 96 F 84 F 81 F 88 M 95 F 80 F 88 M 75 F 76 F 82 F 86 F 76 F 86

Alone, widow With children, widower With a grandchild, widow Alone, widow Alone, widower With children, widow Alone, widow Alone, single With children, widow Alone, widow

P (Participant), F (Female), M (Male)

Primary school Primary school Primary school University Secondary school Secondary school University

Community service Housewife Community service

Forgetfulness, back pain

Housework, volunteering, sewing, Ailments singing Reading, sewing, exercise, gardening Forgetfulness

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First stage: naïve reading For the participants, reaching an advanced age seemed to imply achieving a milestone, and was also understood as having lived experience. This lived experience, however, involved contradictory feelings, for example, noticing age-related changes in the body (such as decreased energy) but not in the mind. The experience of being old also seemed to the interviewees to be related with an awareness of one’s own death. Second phase: structural analysis The content analysis revealed three main themes: Theme I: Reaching advanced age with changes. In one sense, old age was seen by the participants as reaching a milestone. All fourteen respondents used the expression “reaching old age” to convey this notion. They saw reaching old age as a positive achievement, especially if there was no major impact on health, as illustrated by the following verbatim quotes: “Do you want to reach old age? Because if you don’t, then that’s your lot. The longer you go on the better, but you need health, because if old age means being all befuddled, then you might as well go sooner. But that’s not for us to decide. Being old isn’t hard. It’s good to try it, and it’s worse if you don’t. It’s better to give it a try. Getting there, but with your health intact. Because I’ve made it this far.like I am. well. that’s alright, isn’t it?” (P6) Twelve of the 14 interviewees used the expression “keep on going” at some point, with similar but slightly different meanings: wish to keep on going in good health (P2, P5, P6, P9, P11, P13), the duty to keep on going (P8, P11), keep on going if it’s what God wants (P1, P5, P8, P10, P11, P12), keep on going while one can (P2). This might, in one sense, be understood as a positive attitude, a way of coping. “It’s sort of like a ladder, isn’t it. Some people climb up, and keep on climbing. Others stop at some point. They’re made to stop. But that doesn’t mean you should throw in the towel and call it a day. You have to keep going. (.) I mean, who would have thought I’d be doing theater at my age. That’s what tells me I can go on, take another step forward. For as long as God wills. The longer you go on, the better.” (P11) Participants also referred to the experience of physical and functional changes due to their advancing age. In this context, it is interesting to note that some of them reported feeling young at the same time as seeing themselves as old when looking in the mirror.

things you’d like to. So I don’t do them, because that’s the advice I’ve been given.” (P4). They also experienced that their health had worsened and that they were more frail. Some of the participants had experienced an abrupt change in their life, as in the case of a woman who began to feel her age after suffering a fracture: “Nobody takes me for my age, 86. But two months ago I began to feel old. I’d never felt like that. Two months ago I had a fall. I broke a rib and I began to feel like an old woman.” (P14) In terms of the consequences of these changes for everyday life, the participants experienced more restrictions on doing what they wanted. “I can’t manage to do everything. I like to sing, but my voice isn’t what it was. I’d like to read, but my sight’s a bother.” (P12) The perception of reduced autonomy and greater dependence on others for help was experienced overall as something that weighed heavily. Some participants even said that they felt useless or a burden on others. “I want to die. I’m tired now of being here. I think this all the time. Because nothing’s right anymore. I can’t do anything. This [lifts hand] shakes. My leg hurts. And so you feel this weight. You feel you are a burden on others. My daughter has to do almost everything for me. My tablets, she has to be around when I have a shower. it’s a nuisance. If you’re in good health, if your legs and hands work. but me, I try to make some coffee and end up spilling it everywhere. All of it, spilled. I drop almost everything I try to do. Now I have to say: do this for me, do that. It makes me so annoyed. I’d like to be independent enough to do my things. But I have my problems. My hands shake, my leg, can’t you see, and so many other things. That’s what annoys me. Having to ask, time and again”. (P1) Despite these references to a loss of independence, some participants said that they accepted their situation and even felt fortunate in comparison with others who they saw as worse off. “I accept my 85 years, with peace of mind. I’ll settle for this, because I’ve got this far, and I can’t really complain about my health when I see so many people worse off than I am.” (P3)

Most participants mentioned the experience of progressive functional changes such as decreased strength (P3, P4, P8, P13, P14), increased tiredness (P4), less agility (P11), visual problems (P2, P12), changes in voice (P12), hand tremor (P1) or forgetfulness (P12, P14), among others.

With regard to their dependence on others, the participants referred to their reliance on various sources of help, such as the law that enables a relative to take three days off a month in order to help them (P3), a telephone helpline (P4), a home help (P4) and the healthcare in a residential facility (P14). Mention was also made of the important help received through the network of family and friends: children (P1, P3), grandchildren (P4), friends (P11) and others such as the local grocer (P11). However, some participants said that although they had family nearby, they tried to make use of other resources so as not to ask too much of their children:

“I go to bed earlier now. I get more tired. Each year there’s a small change. Five years go by, ten, and when you reach a certain age. the problem is the years going by. But it’s not just that, I don’t have the same strength, and there’s so many things I want to do, but I find sometimes that I need to take things easy, there in my chair. Each year I have to stop because I get tired. I had a problem with back pain. the thing with being 82 is that they don’t let you do the

“Any of my friends will help. The grocer brings my shopping to the door. I’ve got a group of people and things that help me, so I don’t have to be asking my children all the time. Because with your children, it can turn sour. They’ve already got their own problems to deal with, and if they have to sort mine out too, well, then it becomes too much. I don’t want it to come to that”. (P11)

“Changes, changes, year after year. I still don’t feel old, but that’s what I see. In the mirror I’m not the person I once was.” (P13)

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The older people we interviewed also spoke about important barriers in their everyday life, for example, living in an apartment block without a lift (P11) or not being able to go out in cold weather because it made their health worse. In addition, some participants also referred to more positive changes in their experience, for instance, a greater desire to talk to others. “Now, I enjoy talking more, talking about my things. An old man always needs someone to talk to.” (P7) Others said that they had taken up new activities and even discovered new things about themselves. All the participants mentioned activities that they did at the SDC, such as painting, a theater group, an exercise class or sewing (see Table 2), and some of them referred to things they did outside the center, for example, going for a stroll with friends, attending a college for seniors or volunteering. In this context, some of them mentioned having more free time since they had retired, which they took advantage of to travel and to do things that they had previously been unable to. Others, however, said that although they had more free time they also took longer to do things, or in some cases had lost interest in them. “I’ve never had as much free time as now. With all the ups and downs of life. when you’re little you go to school, and what with one thing and another you don’t go to the cinema or theater. You don’t have the ways and means. Things start to pick up when you retire. So many people struggle when they retire and say that they’ve got old. My husband and I, we had some marvelous trips. All the things we didn’t do before, because we couldn’t, well, we did it once we retired. Now I realize I’ve got more free time. Well, it’s obvious. All you have to do is make the effort to survive.” (P11) “In some ways I’ve got more free time, in other ways no. Because there are lots of things I don’t feel like doing. I used to be more interested. Life is winding down.” (P12) Theme II: A long life brings experience. Being an older person was also experienced by participants as having life experience due to all they had learnt from a long life lived. Some of them referred to situations such as being orphaned, as a result of which they experienced things that many people hadn’t. This is illustrated in the following extract: “I’ve had many experiences in life. I’ve learned to do everything, both good and bad. I hope I’ve done more good than bad (.) Experience is the best teacher: If we learn to read it, we can understand it. (.) I have my education, my experience, what I’ve been taught. But let’s not talk about what I know, my experience, because I’m going to be 86. What an age! And then, I’m an orphan and I’ve gone through so many things that others haven’t. You can’t put a price on what experience teaches you.” (P14) Other interviewees made reference to active attempts to learn from their various experiences. “My God, an old man. What does that mean? It means having all this experience and trying to make something of it. That’s what I always try to do. I always try to learn from my mistakes.” (P9) This life experience was also described as a kind of wisdom that can confer on the older person an important role in educating young people. “We have more experience because we’ve been around longer, and so we know about what’s past as well as the present. We always

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know how to give advice, to the young as well. Because they don’t know what life is. Those of us who’ve lived it, how shall I put it, lived the golden years, well, we can tell them a thing or two. Then, they can do what they want. But we’ll teach them. My lot listen to me. Even though I’m old, I still feel useful, both for my grandchildren and children. They ask me for advice, and I’m delighted to give it. I don’t feel useless at home. ” (P13). Not all our participants felt the same, however: “Young people aren’t interested, but our experience is there.” (P7) Reflecting on the past was another common aspect of the lived experience of these older people. “If you look back and start to think, I remember so and so . I always remember the past, look, as long as my mind’s still working. You could write a book about it all.” (P13) For some older people, their memories were cause for sadness when they recalled losses or times of distress: “When I remember these things I feel a bit sad. Do you understand? I wouldn’t want to remember it forever.” (P2) “I remember it all, because I’m a nostalgic kind of person. But when I recall the bad times, then I get sad. You lose things, don’t you, it’s natural. I can’t be as strong as you, can I. You’re young. (.) When I start talking about it, apart from boring whoever has to listen I get all emotional. I might even cry. It brings on an attack.” (P13) Practically all the interviewees also made reference to ‘their day’ and to differences with respect to the present. In general, they felt that when they were young there was a stronger sense of values, and older people were shown more respect. “I think things were better back then. People were more polite, there was more friendship, you helped others. Now it’s just the opposite. There are no values anymore. There used to be respect, but not anymore. My parents were really strict, harsh even, but that’s how I learnt. Nowadays, a kid tells his father what to do. Back then, you listened to your elders. But not anymore. Now you’re an old man and you don’t understand anything. That’s what old age has become, when it should be something positive.” (P9) The experience of the Second World War and the post-war years was something that some older people remembered with great sadness because they lost their parents or a spouse. Others commented that although they recognized that times were hard back then, they preferred it to how things were nowadays because of the stronger sense of values. Theme III: The awareness of death. Finally, the third theme that emerged from the analysis was the awareness of death, of the final stage of life, which was referred to either explicitly or otherwise during the interviews. “I always think about the day they’ll come for me. And I say, the Lord will call for me. Being afraid is part of old age. Because a month goes by and you thank God for granting you another month. You say to yourself: Who knows how long I’ll live, how long I’ve still got to go. Life is hard. There’s some fear. You know that death is a reality. When the time comes, you don’t know what you should do. When it comes

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it comes. It might be another year yet, or two. I’m only afraid when children die. When a young person dies it upsets me.” (P8) The sense that they were approaching the end of life elicited a range of feelings and attitudes in the older people we interviewed. Some of them expressed a fear of dying alone or of not knowing when or how they will die. Others referred to concerns about what will happen next, or about how long they will live. The following quotes are illustrative: “Fear, no (..) but some concern. What will tomorrow be like?” (P9) “I hope someone’s there when I die. Because you get more frightened when you’re alone. The years go by, and the older I get the more fear I have. Not about death itself, but about how I will die, what it will be like. It’s best not to think about it.” (P12) When referring to their awareness of death many of the participants said they were grateful to God for their life, or asked him for help to continue with their journey. “Do you know what I think when I get up in the morning? I say, Lord I am grateful to you for waking me up this morning.” (P2) “Life is a gift. A gift. Don’t take me, Lord, I say to him. I must go on. That’s what I think, how I see it.” (P10) A related sub-theme that emerged in the analysis had to do with the loss of a spouse, which is a frequent occurrence in old age. As already mentioned, all but two of our participants (who were single) had been widowed, and many of them spoke about the challenge of widowhood after a lifetime with their spouse. “The death of my husband was the hardest change in my life. My life was turned upside down. Everything, everything. it was like starting all over. At first, I felt paralyzed. I no longer had the support of the person who I could always turn to, asking: what do I do? That was all gone. So I was completely alone, alone with all the bad thoughts that came to me (.) but little by little I began to pull myself together, through willpower. And then I came here to the center. I’ve managed to fill the days that were empty.” (P11) Comprehensive interpretation and discussion We will now discuss each of the themes that emerged from the analysis and propose a possible meaning of aging in light of the results and the literature review. In the literature it is acknowledged that reaching an advanced age implies physical and functional changes that may differ from one person to another and which do not affect the whole body equally.15 Nevertheless, there comes a time, which varies according to the individual, when the signs of old age appear and when health invariably declines. Although there is some disagreement over the classification of different age bands and the changes most likely to be associated with them, the terms ‘oldeold’ and ‘oldest-old’ are often used to refer, respectively, to persons aged 75e84 and those aged 85þ,30 with greater frailty tending to be observed in advanced old age. The present study included people from both the oldeold and oldest-old categories, all of whom experienced changes (often progressive) in physical function and health. As we saw in the analysis of interviews, it is possible for older people to see themselves as old (i.e., when looking the mirror) yet still feel young at heart. Authors such as Wilde31 refer to this

phenomenon as ‘disembodiment’, since the individual perceives the body to be foreign. It is also worth noting that most of our participants referred to aging as a process involving progressive functional changes. In fact, only one woman identified the specific point at which she began to feel old, which in her case was an accident that significantly affected her ability to live independently. These findings differ from those reported by Nilsson et al,32 who in a phenomenological study of very old persons’ experiences of feeling old found that all those interviewed were able to date the beginning of feeling old. This difference may be due to the fact that we did not specifically ask our participants about when they began to feel old. In line with our findings, the literature highlights that older people often struggle with functional decline, which limits their daily activities and ability to be independent. In this context, authors such as Steenbock-Hult and Sarvimäki33 point out that while dependence and fragility are part of the human condition, there are situations, such as childhood and old age, in which this becomes most apparent.33 This is important to bear in mind, since it may help us to continue respecting the dignity of older persons, even if they become frail and highly dependent on others.34,35 Due to the inclusion criteria, all the participants in our study were at least semi-independent, and we did not include persons with dementia or high levels of dependency. The interviews nonetheless contained frequent references to the fear of becoming completely dependent and, therefore, a burden on others. One interviewee mentioned the feeling of helplessness, and many others said they would rather die than become totally dependent. Another theme in the interviews had to do with a perceived change in the values of society and a negative social view of aging, in contrast to the greater respect that participants felt was shown towards older people when they themselves were young. This reflects the description of contemporary society made by authors such as Phelan,9 who refers to a negative and even ageist point of view. Phelan argues that such a view may also be taken on board by health professionals, thereby highlighting the importance of addressing this issue so as to avoid any negative impact on the care that older persons receive. Sources of help and assistance, such as that provided by relatives or social services, as well as a person’s own inner strengths, are important factors when it comes to improving the degree of independence and helping older persons to cope with the aging process. In this context, Guardini36 emphasizes the need to help older people live this stage of life in a meaningful and positive way, despite their experience of significant losses and limitations. All our participants mentioned receiving help from relatives and/or social services, although they also referred to the activities they took part in at the SDC. With regard to the latter, Browne-Yung et al37 argue that leisure activities may become compensatory strategies for coping with functional limitations. In addition, research suggests that coping with difficult experiences, such as the challenges of aging, may serve as a stimulus of personal growth, provided, as Edo-Gual et al38 point out, these experiences are given meaning and are incorporated into a system of values. One such activity that may, according to Fry and Keyes,39 provide meaningful social interaction and contribute to personal growth is volunteering. Some of our participants did volunteer for groups outside the SDC, and this may be one of the reasons why they were able to accept the limitations associated with old age, to adapt and, as they put it, “to carry on”. Older people like those in our study have travelled almost the entire arc of the different stages of life, and looking back on their lived experience they see a path full of unique, unrepeatable situations. For them, life is coming to an end, in contrast to young people, who usually have many years of life ahead. Thus it is often

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Perspective on aging Changes and limits related with being aged

A long life confers life experience

An awareness of death

Appeal to the meaning of life and aging

Personal response Positive

Negative

- To accept and cope with changes and to discover new possibilities - To work through life experiences - To prepare for death

- To fail to accept the changes experienced - To live anchored in the past, or a meaningless present - To avoid thinking about

Figure 1. Interpretive results [Source: Authors]

said that while making plans is more typical of youth, the task for older people is to see what the life project has amounted to.36 Although advanced age is not necessarily synonymous with wisdom, older persons may, as Bluck and Glück40 point out, be better placed to reflect on the past and to learn from their many years of experience. In this context, Russo41 argues that we need to adopt a patient and respectful attitude towards older people, one that is in keeping with the slower pace of their lives. She adds that although the speech of older persons may at times be repetitive, it is important to bear in mind that remembering and recounting the past is one of the ways in which older people construct their personal narrative, and it may help them in working through their life experiences. In this respect, reminiscence therapy, especially life review, may be a valuable resource, not only for keeping the mind active but also for stimulating reflection on one’s own biography in order to develop meaningful experiences, to promote reconciliation, and to adapt to and cope with difficult life circumstances.42 In addition, reminiscence has been recognized as playing a useful role in relation to maintaining or improving mood, life satisfaction and self-esteem in older people.43 Some authors such as Nygren et al11 and Hinck44 suggest that older people frequently consider the future to be uncertain due to the proximity of death and the sense that their time is running out. Among our participants the awareness of death seemed to be something that might prompt them to re-evaluate their life and values.44 In line with previous studies45 the theme of spirituality and faith in God emerged in relation to the question of life’s meaning in old age. For instance, many participants spoke of their

gratitude for the life they had been given, regarding this d along with continued health in old age d as a gift. Several of those interviewed also made reference to the afterlife, a subject that has been reflected on since the day of classical philosophers such as Plato, Aristotle or Cicero, who referred to the immortality of the soul and the question of judgment and retribution (i.e., death may lead to a better life if the balance of an individual’s actions in this life is positive). In relation to the heightened awareness of death among older persons, much can be learned from the hospice movement and its work on helping people towards closure of important issues (e.g., learning to let go and the work of forgiveness). An approach of this kind could help older people to cope with these issues and to prepare for death. In summary, the meaning of old age appears to be linked to the fact of having lived for so long, to the changes inherent to the aging process, and to the individual’s response to these changes. It is also related to having a long life story that spans the different stages of life, and to the awareness that now, in the final stage, death is not far away. For the older person, this sense of perspective may stimulate further personal growth. By looking back and becoming aware of what has passed and what remains, older people may acquire wisdom in the working through of their lived experience, enabling them to live more fully in the present while preparing for what lies ahead, which for some implies the eternal afterlife. Thus, old age can be experienced as a highly significant period in which one puts the finishing touches to one’s life work, rectifies mistakes, and passes on the wisdom obtained to younger generations.45 Of course, the way in which a person responds to the experience of old

Promoting positive and meaningful aging

Live life to the full - Accept and cope with changes - Discover new possibilities - Consider dependence and frailty as part of the human condition

Work through life experiences - Use of reminiscence - Foster interpersonal relationships

Prepare for the future - Help to close issues - Help to prepare for death

Figure 2. Proposal for promoting positive and meaningful aging [Source: Authors]

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Supplementary data

age will depend on his or her individual history and the resources that he or she has available for dealing with the present. Consequently, and as shown in Fig. 1, there are several possible responses to the reality of old age.

Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.gerinurse.2017.04.010

Translation to clinical usefulness

References

In order to enable older people to live life to the full, health professionals and caregivers should help them to find meaning in life despite any limitations or adverse life circumstances, such as becoming dependent, that they may have to face.36,45,46 They should also be encouraged to develop interpersonal relationships with people of their own generation, in order to reflect on all they have lived through, as well as with people from younger generations, to whom they could impart their values, lived experience, and traditions. Coping with the question of their own death is another issue that needs to be addressed sensitively, and here the potentially important role played by a person’s spiritual beliefs should be taken into consideration.47,48 Fig. 2 summarizes these proposals.

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Limitations The first limitation of this study concerns language. The older people we interviewed came from various parts of Italy where different dialects are spoken, although all of them spoke and understood Italian well. Furthermore, Italian is not the mother tongue of the researcher who conducted the interviews, although after living in Italy for seven years she has a thorough knowledge of this language; in addition, one of the co-authors is Italian and was able to assess the results and their presentation. Although we sought to introduce a degree of variability into the sample (in terms of age, gender, social and financial status, and level of education) the fact that the study was conducted in a single setting (i.e., a social day center in Rome) is a further limitation to bear in mind with regard to the transferability of results. Nevertheless, the proposed interpretation of the meaning of old age may still serve as a platform for future research in this area. Implications for practice By broadening our knowledge of people’s experience of aging and its meaning for them, the findings of this hermeneutic phenomenological study could help family members, caregivers, and health professionals to deepen their own understanding of this experience and to show greater empathy towards older people.28 As such, the results might also help to promote person-centered care. In order to explore the possible applications of our phenomenological findings, we read a report of the results to a group of staff at the SDC. They reported that the experience had given them food for thought and that they now had a better understanding of what older people feel. Overall, the findings highlight the importance of helping older people give meaning to their aging process. There is clearly a role here for interventions that enable them to experience aging as a positive and meaningful process, and which can encourage them to see it as a continued source of reflection. Acknowledgments The authors experiences.

thank

the

participants,

for

sharing

their

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