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Social aspects of ageing
ASPECTS OF AGEING
Social aspects of ageing
Quality of life for older people There is now a considerable literature highlighting what is important to older people’s quality of life (Bond and Corner, 2004); the key domains are summarized in Figure 1. The factors that older people mention are the same as those in other age groups and broadly include: • relationships with family and friends • social contacts • own health • independence • mobility • emotional well-being • material circumstances • religion/spirituality • leisure activities • home environment (Farquhar, 1995). The aspects of life cited by older people as being most important are listed in Figure 2. Social environmental factors such as social integration, the importance of having a purpose in life and belonging to a community have all been identified as being important to quality of life (Bamford and Bruce, 2000). Other factors include self-esteem, a sense of self and identity, a sense of control and spiritual wellbeing. These concepts are important to older people in giving a positive view of themselves, and have an impact on their relationships with friends and families and their activities. The concepts are also important to their continuing ability over the life-course to manage their lives, adapt to changes and see meaning in their lives (Fry, 2000). A key to understanding successful ageing (Baltes and
Lynne Corner Katie Brittain John Bond
Ageing in contemporary society Human lifespans are increasing steadily worldwide, mainly as a result of improvements in living conditions, sanitation and health care. Yet in spite of the success of this demographic revolution, age stratification and discrimination is widespread, and in most Western cultures older people are marginalized and socially excluded on the basis of age. Stereotypes of older people are essentially negative and reinforce institutionalized ageism, which is reinforced in turn by the legal, political, educational and health and welfare structures of modern society. Of course, such generalizations mask huge diversity, and like the rest of the population there are differences in the following domains: • gender • race and ethnicity • socioeconomic group/social class • income/pensions • regional/local cultures • household and/or family structure (Bond et al., 1993; Joint Taskforce on Older People, 2000). Ageing is a normal process, beginning at birth and ending with death, and chronological age is merely a proxy for biological and social ageing. So, just as a 60-year-old is not the same as an 85year-old, two 85-year-olds will be very different from each other as they have different biographies, individual life experiences and self-identities.
Domains relevant to the quality of life of older people • Subjective satisfaction: global quality of life as assessed by individual older person • Physical environmental factors: standard of housing or institutional living arrangements; control over physical environment; access to facilities such as shops, public transport and leisure providers
Lynne Cornerr is an Alzheimer’s Society Research Fellow at the Centre for Health Services Research and Institute for Ageing and Health, University of Newcastle, Newcastle upon Tyne, UK. She specializes in researching the psychosocial and economic aspects of dementia and assessing quality of life.
• Social/environmental factors: family and social networks and support; levels of recreational activity; contact with statutory and voluntary organizations
Katie Brittain is a Research Associate at the Centre for Health Services Research, University of Newcastle, Newcastle upon Tyne, UK. Her research interests include the social impact of stroke and incontinence on older people and on informal carers.
• Cultural factors: age, gender, ethnic, religious and class background
• Socioeconomic factors: income and wealth, nutrition and overall standard of living
• Health status factors: physical well-being, functional ability and mental health • Personality factors: psychological well-being, morale, life satisfaction and happiness
John Bond d is Professor of Social Gerontology and Health Services Research at the University of Newcastle, Newcastle upon Tyne, UK. He is Director of the Centre for Health Services Research and a member of the Institute for Ageing and Health. He specializes in researching the psychosocial and economic aspects of dementia and contributing to clinical trials of interventions for older people.
PSYCHIATRY 3:12
• Personal autonomy factors: ability to make choices, exercise control and negotiate own environment 1
5
© 2004 The Medicine Publishing Company Ltd
ASPECTS OF AGEING
Important areas of life for older people
Key indicators of successful ageing
Most important (%)1
Proportion identifying any of top (%)2
Own health
40
63
Family relationships
24
47
Health of close person
16
30
Standard of living
9
43
Social activities
2
21
Spiritual or religious
2
6
Other relationships
2
13
Environment
1
8
Other
4
–
Total
100
Number of respondents
409
• • • • • • •
Area of life
Length of life Biological health Mental health Cognitive efficacy Social competence and productivity Personal control Life satisfaction
(Source: Baltes and Baltes, 1990)
3
What are the experiences of older people? Case study: Bob and Mary The following case study is intended to illustrate how an understanding of a person’s life biography is crucial to understanding what is important to, and what influences, their quality of life. Bob (aged 67) and Mary (aged 65) had been married for 35 years. Bob was a keen long-distance runner; for over 35 years he had been an active member of a local running club, training with fellow members for marathons, completing daily training runs and exercising in the gym. Through the running club he had competed regularly, completing over 25 half-marathons and – the crowning of his achievements – running a local marathon in 3 hours 10 minutes. The running club also constituted a major part of his social life and he had many close friendships with other club members. Running and keeping physically fit were clearly important to Bob’s quality of life and his sense of identity.
410
1
Subject to rounding error
2
Percentages add to more than 100% as this question was multicoded
(Source: Bowling, 1995)
2
Baltes, 1990) (see Figure 3) and quality of life is to appreciate the interactions between the different domains, contextualized within different individuals’ life biographies. The importance of domains may change across the life-course and there may be differences between social and cultural groups.
Social exclusion Bob had been experiencing memory problems for 6 years when he was diagnosed with probable Alzheimer’s disease. The impact of the stigma of the disease on Bob’s life was immediate; shortly after his diagnosis, Bob withdrew from running. Friends from the local club no longer contacted him to join them. This was particularly hurtful to Bob and he felt unable to contact his friends, and his closest friend in particular, for an explanation as to why the contact had ceased. Of course, it was not only Bob who experienced the negative effects of stigma. Mary was also subject to ‘courtesy stigma’, the term coined by Goffman to describe the situation when an individual ‘is related through the social structure to a stigmatized individual … society treats both individuals in some respect as one’ (Goffman, 1968).
Ageing and health An enduring negative image of later life is of restrictions because of increasingly failing physical health and disability and diminished personal and social opportunities. Of course, the social and psychological impact of chronic illness on coping mechanisms and lifestyles of individuals and their family and friends is momentous (Bury, 1982), and represents a major challenge both to society and to health-care professionals, who must help people achieve and maintain optimum quality of life. Ill-health in later life is a source of pain and suffering and can bring losses to the individual, including those of independence and autonomy, self-esteem and dignity, mobility, social interaction and participation in everyday life. But although ill-health and disability increase with age, the majority of older people remain independent and healthy. From the dominant biomedical perspective, the focus tends to be on the ‘problems’ of the individual patient, in spite of the broader social, economic and political contexts that structure them. For example, it is often assumed that older people are socially isolated, yet in reality only 20% of people over the age of 65 live alone, and they might in fact choose to do so, as people from any other group might. It is also incorrect to equate living alone with loneliness and to equate loneliness with social isolation (Victor et al., 2000).
PSYCHIATRY 3:12
Perceptions of risk and insight One impact of stigma is to exclude stigmatized individuals from their normal social world. Thus, Mary felt Bob could no longer go out running by himself – focusing on the risks involved and the potential consequences. She expressed her fear of him being hurt, getting lost and being unable to find his way home, even though there was no evidence that this had happened before the diagnosis of probable Alzheimer’s disease. Bob said that he wished he could still run, and felt that he still could. Physically, he remained fit and lean. But others had placed restrictions on his choices and excluded him from his favourite social activity and
6
© 2004 The Medicine Publishing Company Ltd
ASPECTS OF AGEING
pastime. Judgements were made about him by others regarding lack of insight and perceptions of risk. He had been denied practical citizenship because of his cognitive abilities. No attempt was made to facilitate Bob’s enjoyment of running. For example, there was an enclosed park nearby that he could have run in, but Mary deemed this to be an unacceptable risk. Professionals legitimized Mary’s feelings, and no one tried to understand just how important running was to Bob’s self-concept. The increasing emphasis on his cognitive deficits had a major effect on his quality of life, and a catastrophic effect on how he perceived himself. The behaviours characteristic of people with dementia clearly challenge social norms regarding appropriate conduct, and it is likely that it was the expectation of such behaviour that kept Bob’s friends away.
Bamford C, Bruce E. Defining the outcomes of community care: the perspectives of older people with dementia and their carers. Ageing Socc 2000; 20: 543–70. Bond J, Coleman P, Peace S. Ageing in Society: An Introduction to Social Gerontology. London: Sage, 1993. Bond J, Corner L. Quality of Life and Older People. Buckingham: Open University Press, 2004. Bond J, Graham R, Corner L. Social science theory on dementia research: normal ageing, cultural representation and social exclusion. In: Innes A, Archibald C, Murphy C, eds. Dementia and Social Inclusion: Marginalised Groups and Marginalised Areas of Dementia Research, Care and Practice. London: Jessica Kingsley, 2004. Bury M. Chronic illness as biographical disruption. Sociol Health Illn 1982; 4: 167–82. Farquhar M. Elderly people’s definitions of quality of life. Soc Sci Med 1995; 41: 1439–46. Fry P S. Whose quality of life is it anyway? Why not ask seniors to tell us about it? Int J Aging Hum Dev 2000; 50: 361–83. Goffman E. Stigma: Notes on the Management of Spoiled Identity. Harmondsworth: Penguin, 1968. Joint Taskforce on Older People. Healthcare and Ageing Population Panels. London: Department of Trade and Industry, 2000. Post S. The Moral Challenge of Alzheimer’s Disease. Baltimore, MD: Johns Hopkins University Press, 1995. Victor C, Scambler S, Bond J, Bowling A. Being alone in later life: loneliness, social isolation and living alone. Rev Clin Gerontol 2000; 10: 407–17.
Cultural representation of older people Stigma and discrimination An important aspect of the cultural representation of dementia and other mental illnesses is the inherent stereotyping of older people with dementia and the stigmatizing effect on everyday interactions and the quality of life they experience. Reducing the effects of stigma is high on the research and political agenda, and stigma remains a major obstacle to ensuring good care for people with mental disorders (World Health Organization and World Psychiatric Association, 2002). In our ‘hypercognitive culture’ (Post, 1995), people with dementia are excluded because they lack ‘cognitive citizenship’ (Bond et al., 2004). Whether a person is given a diagnosis of dementia, experiences a stroke or loses a loved one, such events change the way that other people respond to the older person and this affects their life, often increasing their social isolation and marginalization. Goffman (1968) refers to stigma as a relationship of devaluation in which one individual is disqualified from full social acceptance. Stigma is a social attribute that is discrediting for an individual or group. It seems likely that people with dementia would be stigmatized because of the ‘out of the ordinary’ or problematic behaviours that can occur.
FURTHER READING Bowling A. The most important things in life: comparisons between older and younger population age groups by gender: results from a national survey of the public’s judgements. Int J Health Sci 1995; 6: 169–75. World Health Organization and World Psychiatric Association. Reducing Stigma and Discrimination Against Older People with Mental Disorders. Geneva: WHO, 2002.
Overcoming stigma Stigma is a major barrier to increased participation, both for the person with dementia and for their informal caregiver(s). Ways need to be found of neutralizing the effects of stigma in order to achieve the aim of greater social participation for this marginalized group. It will be at the societal level where most change must occur. The publicity generated by advocates of people with dementia and the ‘coming out’ of famous people with dementia (such as the former US president Ronald Reagan) will have the greatest impact on making dementia a less discreditable condition. The challenge remains how to increase social inclusion for all older citizens. The hegemony of institutionalized ageism and the negative cultural representation of older people remain major barriers.
REFERENCES Baltes P B, Baltes M M. Successful Aging: Perspectives from the Behavioral Sciences. Cambridge: Cambridge University Press, 1990.
PSYCHIATRY 3:12
7
© 2004 The Medicine Publishing Company Ltd
Social aspects of ageing
Quality of life for older people There is now a considerable literature highlighting what is important to older people’s quality of life (Bond and Corner, 2004); the key domains are summarized in Figure 1. The factors that older people mention are the same as those in other age groups and broadly include: • relationships with family and friends • social contacts • own health • independence • mobility • emotional well-being • material circumstances • religion/spirituality • leisure activities • home environment (Farquhar, 1995). The aspects of life cited by older people as being most important are listed in Figure 2. Social environmental factors such as social integration, the importance of having a purpose in life and belonging to a community have all been identified as being important to quality of life (Bamford and Bruce, 2000). Other factors include self-esteem, a sense of self and identity, a sense of control and spiritual wellbeing. These concepts are important to older people in giving a positive view of themselves, and have an impact on their relationships with friends and families and their activities. The concepts are also important to their continuing ability over the life-course to manage their lives, adapt to changes and see meaning in their lives (Fry, 2000). A key to understanding successful ageing (Baltes and
Lynne Corner Katie Brittain John Bond
Ageing in contemporary society Human lifespans are increasing steadily worldwide, mainly as a result of improvements in living conditions, sanitation and health care. Yet in spite of the success of this demographic revolution, age stratification and discrimination is widespread, and in most Western cultures older people are marginalized and socially excluded on the basis of age. Stereotypes of older people are essentially negative and reinforce institutionalized ageism, which is reinforced in turn by the legal, political, educational and health and welfare structures of modern society. Of course, such generalizations mask huge diversity, and like the rest of the population there are differences in the following domains: • gender • race and ethnicity • socioeconomic group/social class • income/pensions • regional/local cultures • household and/or family structure (Bond et al., 1993; Joint Taskforce on Older People, 2000). Ageing is a normal process, beginning at birth and ending with death, and chronological age is merely a proxy for biological and social ageing. So, just as a 60-year-old is not the same as an 85year-old, two 85-year-olds will be very different from each other as they have different biographies, individual life experiences and self-identities.
Domains relevant to the quality of life of older people • Subjective satisfaction: global quality of life as assessed by individual older person • Physical environmental factors: standard of housing or institutional living arrangements; control over physical environment; access to facilities such as shops, public transport and leisure providers
Lynne Cornerr is an Alzheimer’s Society Research Fellow at the Centre for Health Services Research and Institute for Ageing and Health, University of Newcastle, Newcastle upon Tyne, UK. She specializes in researching the psychosocial and economic aspects of dementia and assessing quality of life.
• Social/environmental factors: family and social networks and support; levels of recreational activity; contact with statutory and voluntary organizations
Katie Brittain is a Research Associate at the Centre for Health Services Research, University of Newcastle, Newcastle upon Tyne, UK. Her research interests include the social impact of stroke and incontinence on older people and on informal carers.
• Cultural factors: age, gender, ethnic, religious and class background
• Socioeconomic factors: income and wealth, nutrition and overall standard of living
• Health status factors: physical well-being, functional ability and mental health • Personality factors: psychological well-being, morale, life satisfaction and happiness
John Bond d is Professor of Social Gerontology and Health Services Research at the University of Newcastle, Newcastle upon Tyne, UK. He is Director of the Centre for Health Services Research and a member of the Institute for Ageing and Health. He specializes in researching the psychosocial and economic aspects of dementia and contributing to clinical trials of interventions for older people.
PSYCHIATRY 3:12
• Personal autonomy factors: ability to make choices, exercise control and negotiate own environment 1
5
© 2004 The Medicine Publishing Company Ltd
ASPECTS OF AGEING
Important areas of life for older people
Key indicators of successful ageing
Most important (%)1
Proportion identifying any of top (%)2
Own health
40
63
Family relationships
24
47
Health of close person
16
30
Standard of living
9
43
Social activities
2
21
Spiritual or religious
2
6
Other relationships
2
13
Environment
1
8
Other
4
–
Total
100
Number of respondents
409
• • • • • • •
Area of life
Length of life Biological health Mental health Cognitive efficacy Social competence and productivity Personal control Life satisfaction
(Source: Baltes and Baltes, 1990)
3
What are the experiences of older people? Case study: Bob and Mary The following case study is intended to illustrate how an understanding of a person’s life biography is crucial to understanding what is important to, and what influences, their quality of life. Bob (aged 67) and Mary (aged 65) had been married for 35 years. Bob was a keen long-distance runner; for over 35 years he had been an active member of a local running club, training with fellow members for marathons, completing daily training runs and exercising in the gym. Through the running club he had competed regularly, completing over 25 half-marathons and – the crowning of his achievements – running a local marathon in 3 hours 10 minutes. The running club also constituted a major part of his social life and he had many close friendships with other club members. Running and keeping physically fit were clearly important to Bob’s quality of life and his sense of identity.
410
1
Subject to rounding error
2
Percentages add to more than 100% as this question was multicoded
(Source: Bowling, 1995)
2
Baltes, 1990) (see Figure 3) and quality of life is to appreciate the interactions between the different domains, contextualized within different individuals’ life biographies. The importance of domains may change across the life-course and there may be differences between social and cultural groups.
Social exclusion Bob had been experiencing memory problems for 6 years when he was diagnosed with probable Alzheimer’s disease. The impact of the stigma of the disease on Bob’s life was immediate; shortly after his diagnosis, Bob withdrew from running. Friends from the local club no longer contacted him to join them. This was particularly hurtful to Bob and he felt unable to contact his friends, and his closest friend in particular, for an explanation as to why the contact had ceased. Of course, it was not only Bob who experienced the negative effects of stigma. Mary was also subject to ‘courtesy stigma’, the term coined by Goffman to describe the situation when an individual ‘is related through the social structure to a stigmatized individual … society treats both individuals in some respect as one’ (Goffman, 1968).
Ageing and health An enduring negative image of later life is of restrictions because of increasingly failing physical health and disability and diminished personal and social opportunities. Of course, the social and psychological impact of chronic illness on coping mechanisms and lifestyles of individuals and their family and friends is momentous (Bury, 1982), and represents a major challenge both to society and to health-care professionals, who must help people achieve and maintain optimum quality of life. Ill-health in later life is a source of pain and suffering and can bring losses to the individual, including those of independence and autonomy, self-esteem and dignity, mobility, social interaction and participation in everyday life. But although ill-health and disability increase with age, the majority of older people remain independent and healthy. From the dominant biomedical perspective, the focus tends to be on the ‘problems’ of the individual patient, in spite of the broader social, economic and political contexts that structure them. For example, it is often assumed that older people are socially isolated, yet in reality only 20% of people over the age of 65 live alone, and they might in fact choose to do so, as people from any other group might. It is also incorrect to equate living alone with loneliness and to equate loneliness with social isolation (Victor et al., 2000).
PSYCHIATRY 3:12
Perceptions of risk and insight One impact of stigma is to exclude stigmatized individuals from their normal social world. Thus, Mary felt Bob could no longer go out running by himself – focusing on the risks involved and the potential consequences. She expressed her fear of him being hurt, getting lost and being unable to find his way home, even though there was no evidence that this had happened before the diagnosis of probable Alzheimer’s disease. Bob said that he wished he could still run, and felt that he still could. Physically, he remained fit and lean. But others had placed restrictions on his choices and excluded him from his favourite social activity and
6
© 2004 The Medicine Publishing Company Ltd
ASPECTS OF AGEING
pastime. Judgements were made about him by others regarding lack of insight and perceptions of risk. He had been denied practical citizenship because of his cognitive abilities. No attempt was made to facilitate Bob’s enjoyment of running. For example, there was an enclosed park nearby that he could have run in, but Mary deemed this to be an unacceptable risk. Professionals legitimized Mary’s feelings, and no one tried to understand just how important running was to Bob’s self-concept. The increasing emphasis on his cognitive deficits had a major effect on his quality of life, and a catastrophic effect on how he perceived himself. The behaviours characteristic of people with dementia clearly challenge social norms regarding appropriate conduct, and it is likely that it was the expectation of such behaviour that kept Bob’s friends away.
Bamford C, Bruce E. Defining the outcomes of community care: the perspectives of older people with dementia and their carers. Ageing Socc 2000; 20: 543–70. Bond J, Coleman P, Peace S. Ageing in Society: An Introduction to Social Gerontology. London: Sage, 1993. Bond J, Corner L. Quality of Life and Older People. Buckingham: Open University Press, 2004. Bond J, Graham R, Corner L. Social science theory on dementia research: normal ageing, cultural representation and social exclusion. In: Innes A, Archibald C, Murphy C, eds. Dementia and Social Inclusion: Marginalised Groups and Marginalised Areas of Dementia Research, Care and Practice. London: Jessica Kingsley, 2004. Bury M. Chronic illness as biographical disruption. Sociol Health Illn 1982; 4: 167–82. Farquhar M. Elderly people’s definitions of quality of life. Soc Sci Med 1995; 41: 1439–46. Fry P S. Whose quality of life is it anyway? Why not ask seniors to tell us about it? Int J Aging Hum Dev 2000; 50: 361–83. Goffman E. Stigma: Notes on the Management of Spoiled Identity. Harmondsworth: Penguin, 1968. Joint Taskforce on Older People. Healthcare and Ageing Population Panels. London: Department of Trade and Industry, 2000. Post S. The Moral Challenge of Alzheimer’s Disease. Baltimore, MD: Johns Hopkins University Press, 1995. Victor C, Scambler S, Bond J, Bowling A. Being alone in later life: loneliness, social isolation and living alone. Rev Clin Gerontol 2000; 10: 407–17.
Cultural representation of older people Stigma and discrimination An important aspect of the cultural representation of dementia and other mental illnesses is the inherent stereotyping of older people with dementia and the stigmatizing effect on everyday interactions and the quality of life they experience. Reducing the effects of stigma is high on the research and political agenda, and stigma remains a major obstacle to ensuring good care for people with mental disorders (World Health Organization and World Psychiatric Association, 2002). In our ‘hypercognitive culture’ (Post, 1995), people with dementia are excluded because they lack ‘cognitive citizenship’ (Bond et al., 2004). Whether a person is given a diagnosis of dementia, experiences a stroke or loses a loved one, such events change the way that other people respond to the older person and this affects their life, often increasing their social isolation and marginalization. Goffman (1968) refers to stigma as a relationship of devaluation in which one individual is disqualified from full social acceptance. Stigma is a social attribute that is discrediting for an individual or group. It seems likely that people with dementia would be stigmatized because of the ‘out of the ordinary’ or problematic behaviours that can occur.
FURTHER READING Bowling A. The most important things in life: comparisons between older and younger population age groups by gender: results from a national survey of the public’s judgements. Int J Health Sci 1995; 6: 169–75. World Health Organization and World Psychiatric Association. Reducing Stigma and Discrimination Against Older People with Mental Disorders. Geneva: WHO, 2002.
Overcoming stigma Stigma is a major barrier to increased participation, both for the person with dementia and for their informal caregiver(s). Ways need to be found of neutralizing the effects of stigma in order to achieve the aim of greater social participation for this marginalized group. It will be at the societal level where most change must occur. The publicity generated by advocates of people with dementia and the ‘coming out’ of famous people with dementia (such as the former US president Ronald Reagan) will have the greatest impact on making dementia a less discreditable condition. The challenge remains how to increase social inclusion for all older citizens. The hegemony of institutionalized ageism and the negative cultural representation of older people remain major barriers.
REFERENCES Baltes P B, Baltes M M. Successful Aging: Perspectives from the Behavioral Sciences. Cambridge: Cambridge University Press, 1990.
PSYCHIATRY 3:12
7
© 2004 The Medicine Publishing Company Ltd